Plan of Care
Welcome! In this video we will be covering nursing care plans.
A nursing care plan is developed to guide nursing care for individual patients and communities. It serves as a model to give individualized care to a patient, or on a larger scale, direct care for a group of individuals.
It is not a medical diagnosis or medical plan, but it is a vital part of patient care.
Nursing care plans have changed and evolved over the years as nursing practices have advanced. This is based on evidence, science, trends in the population, community health concerns, and other health needs as they arise.
The 5 Essential Steps in Nursing Care Plans
The nursing care plan consists of 5 steps that follow the acronym ‘AD-PIE’… Assessment, Diagnosis, Planning, Intervention, and Evaluation.
The first and most important part of a nursing care plan is the assessment. When a patient or population interfaces with healthcare, or when a healthcare professional sees a need, the first step is to gather data.
Let’s start with the patient report, which is the subjective data. This is what the patient reports to the nurse as the problem. The patient also gives the nurse their past medical history, and a variety of questions can be asked at this time as to the status of their current state of health.
Next, the nurse verifies the patient report by collecting objective data, the measurable data of the physical assessment, such as vital signs, height and weight.
The physical assessment of a patient to develop a plan of care utilizes the tools of: Inspection, Percussion, Palpation, Auscultation, and performance of minor testing, to gather data about the patient to form a nursing diagnosis.
Inspection simply means to look at the patient. Look at their posture, skin, signs of distress, lumps, bumps, bruises, deformities, and make a note of anything you find. Always compare one side of the body to another and inquire if this is the patient’s baseline. Often the subjective questions a patient is asked about their health history can be gathered while their physical assessment is performed.
Percussion is a technique where you use your hands to elicit certain types of sounds by tapping on your fingers as they are placed on various parts of the patient’s body. For example, you would expect to percuss dullness over bone or an organ, and tympani over the intestines. If the opposite is found, this may be an abnormal finding.
Palpation is touching the patient and pressing in. Light palpation is about an inch, deeper palpation about 1.5 to 2 inches. This can help us feel something abnormal or elicit a pain response from the patient.
Auscultation involves using a stethoscope to listen for sounds such as the heartbeat, or breathing of the lungs.
Some minor testing can also be done, such as using a reflex hammer to test reflexes or observing a patient’s gait as they walk across the room.
Once all the subjective and objective data have been gathered, a nursing diagnosis can be created based on problems or potential problems you assess. Nursing diagnoses are a way of identifying actual or potential health problems that can be prevented or resolved by independent nursing intervention. The North American Nursing Diagnosis Association (NANDA) provides nurses with a current list of nursing diagnoses.
The next stage in the nursing care plan is the planning stage, where goals and outcomes are formulated. These patient-specific goals provide a course of direction for a personalized plan of care. Goals should be specific, measurable, attainable, realistic, and timely.
The fourth step in the nursing care plan is intervention. Intervention involves actually doing the care the patient requires, such as administering medication or turning the patient in bed. Rationales for these interventions are included to show that the intervention is evidence-based.
The last step of the nursing care plan is evaluation of the interventions. Based on the patient’s response to the interventions, they can continue or be reassessed if not achieving the expected outcome.
Nursing diagnoses do not always have to be an actual problem. They can also be a potential problem, or a lack of knowledge regarding health, or something the patient may be at risk for, such as in prolonged bed rest, which may cause them to be at risk for skin breakdown.
Currently, in addition to using the standard linear way to document a nursing care plan, we have seen the development of nursing care planning through concept mapping, which is just another way to look at the assessment, plan interventions, and evaluation through a map of sorts versus the standard linear way of writing them.
Thanks for watching, and happy studying!
