Medicine has changed greatly over the last few generations. The days when patients repeatedly visited the same family physician are gone. Today, patients commonly consult teams of specialists, including—but not limited to—doctors and nurses.
These care teams are greatly assisted by records that document a patient’s history and medical treatment and chart a health care plan, often referred to as a nursing care plan. Though this medical “road map” has long been associated with nursing, it actually involves an interdisciplinary team. A caregiver unfamiliar with a patient/resident should be able to find all the information needed to care for a patient in the care plan.
The first step in care planning is quality assessment, followed by reassessments, if necessary. There are established protocols for initial assessments and ongoing reevaluations, depending on the situation.
The initial assessment is used to generate a “problem” list, which may be as simple as a list of medical diagnoses. Despite its name, this list may also include a patient/resident’s strengths, along with family or relationship problems which may affect the person’s overall well-being.
A health care provider can consult the list, asking whether each problem will get better (or “Can we make it better?”). If the answer is yes, then the goal becomes resolving or improving the problem.
If the answer is no, the health care provider asks another question: “Can we keep this from getting any worse or developing complications?” Diabetes and congestive heart failure are examples of problems which typically don’t get better but can be managed. The health care provider should set down specific and measurable goals, such as maintain blood sugar within an acceptable range.
Alzheimer’s disease and nutritional problems associated with a terminal condition are examples of problems that call for the final question: “How can we make this person’s remaining days as comfortable and dignified as possible?” The goal then becomes providing optimal quality of life. Ironically, this may be the most complex scenario, as the health care team, the patient and the patient’s relatives may not always agree on what quality of life entails.
Obviously, according to nursingpaper.org, a nursing care plan must be flexible, adapting to changes in the patient’s condition and circumstances. The care planning process ends when the patient or resident is discharged or dies.
RESPIRATORY
Resp rate and quality. Chest wall movement, breath sounds. Cough, wheezing, sputum, SOB, orthopnea, pain. Resp disorders, surgeries, O2 use, smoking/tobacco use, PPD skin test
GASTROINTESTINAL
Abd tone, tenderness, contour, distention, scars. Bowel sounds - quality and location. Last BM (date and character). Condition of mucous membranes, gums, teeth, and tounge. Unusual BM patterns, indigestion, jaundice.
GENITOURINARY
Note bladder distention, dysuria, frequency, hematuria, nocturia. Voiding patterns. Urine color, clarity, odor. Vaginal or penile drainage, lesions. LMP. Incotinence, urine output - 8 hr and 24 hr. Last pap smear, mammogram and breast exam
INTEGUMENTARY
Decubitus, lesions, rashes, bruises, scars. Color, temp, moisture, turgor. Hair, nails, skin, texture, pallor cyanosis.
ENDOCRINE
Any diabetes, adrenal or thyroid disorders. Blood glucose levels if appropriate
NUTRITION
Diet, amount eaten (%). Dentures. Height and weight, IBW. # of meals eaten a day. Disorders, i.e. anorexia, nausea, vomiting. If trube feeding, calories in 24 hours. Recent weight loss or gain. Intake for 8 and 24 hours (separate po, IV, NG)
Nursing Diagnosis
ETIOLOGY OF THE PROBLEM: Why it can occur.
Scientific Rationale
Why the signs and symptoms occur Sources and pages needed for each
Evaluation
Was the STG met? Why or why not? Assesment results Were all nursing interventions done? Why or why not? Changes in plan of care.
