Description
Care Plan Information
The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. A care plan is your roadmap for effective nursing care and a collaboration tool that improves the entire healthcare process. These are the main reasons to write a care plan:
Organized and systematic plan to deliver nursing care
Focuses on patient-centered care
Enhances nursing team collaboration
Facilitates documentation and compliance
This assignment is designed to enhance your clinical reasoning and critical thinking skills as you develop a care plan for either an antepartum, intrapartum, or post-partum patient.
Instructions
Select a patient that you have cared for during any clinical session.
Complete all required information on the “Data Collection Sheet and Nursing Care Plan.docxLinks to an external site.
Identify and list all relevant nursing assessments, diagnoses, planning factors/goals, implementation strategies, and evaluations relevant to the patient you have chosen to plan care for.
The following are required to consider this assignment complete:
Data collection portion complete.
Correctly identifies all actual and potential nursing diagnoses and relates to pt history.
Correctly states selected nursing diagnoses (physiologic, psychosocial, knowledge deficit), including related to/as manifested by.
Establishes realistic goals to support nursing diagnoses.
Establishes measurable goal statements.
Short-term goals support achievement of long-term goals.
Interventions are clear and concise.
Interventions clearly support related goals.
Interventions include frequency of action.
Rationales clearly support inclusion of intervention in care plan.
Expected outcomes relate to the interventions.
Evaluation statements are clear and concise.
References include at least two course textbooks and one nursing journal article.
Care plan is typed and free of spelling, syntax, and grammatical errors.
Care plan template is appropriately used.
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