Nursing care plans and diagnoses identify existing or potential problems and outline a course of action to provide the best possible care to the patient. A care plan consists of diagnoses, goals and interventions.
Assessment
Before a diagnosis can be written, the nurse needs to gather all pertinent information from any available source. These include patient interviews, charts and other medical professionals involved in his care.
Diagnosing
Once all the information is gathered, the nurse writes one or more nursing diagnoses identifying existing or possible health concerns. The diagnosis states the problem and backs it up with evidence.
Goals
The next step in creating a care plan is establishing reasonable goals related to the diagnoses. If possible, include the patient in this process as much as possible to help give her a sense of control.
Interventions
Interventions are actions the nurse can take to help the patient meet the goals. Many hospitals use a standardized list of interventions to make coding easier.
Adaptability
Every care plan must be adaptable to the patient's current situation. Goals can change and interventions can fail, so be ready to alter the plan as needed. A is a guideline, not a rule book.
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