USING NURSING CARE PLANS

Nursing Diagnosis And Intervention
The nursing care plan is best thought of as a written re­flection of the nursing process: What does the assessment reveal? What should be done? How, when, and where should these planned interventions be carried out? What is the desired outcome? That is, Will the delivery of planned interventions result in the desired goal? The nurse's ability to carry out this process in a systematic fashion, using all available information and resources, is the fundamental basis for nursing practice. This process includes correctly identifying existing needs, as well as recognizing potential needs and/or risks. Planning and de­livering care in an individualized fashion to address these actual or potential needs, as well as evaluating the effec­tiveness of that care, is the basis for excellence in nursing practice. Forming a partnership with the patient and/or caregiver in this process and humanizing the experience of being a care recipient is the essence of nursing.
The Assessment

All the information that the nurse collects regarding a particular patient makes up the assessment. This assess­ment allows a nursing diagnosis, or summary judgment, to be made. This, in turn, drives the identification of ex­pected outcomes ( what is desired by and for this par­ticular patient in relation to this identified need) and the plan of care. Without a comprehensive assessment, all else is a "shot in the dark."
Nurses have always carried out the task of assess­ment. As science progresses, technology develops, infor­mation is more abundant than at any other time in his­tory, and length of contact with each patient becomes shorter, astute assessment skills are essential in a nurse's ability to plan and deliver effective nursing care.
Assessment data are abundant in any clinical setting. What the nurse observes; what a history (written or ver­bal) reveals; what the patient and/or caregiver reports (or fails to report) about a situation, problem, or con­cern; and what laboratory and other diagnostic infor­mation is available are all valid and important data.