Nursing Diagnosis and Care Plan
A nursing diagnosis is a clinical judgment that identifies a patient’s actual or potential health problem or need, based on an assessment of the patient’s signs, symptoms, and responses to interventions. A nursing care plan is a document that outlines the goals, interventions, and expected outcomes for a patient’s care, based on the nursing diagnosis. A nursing care plan helps nurses to communicate, coordinate, and evaluate the patient’s care.
The process of developing a nursing diagnosis and care plan involves four steps:
1. Collecting data: The nurse gathers information about the patient’s physical, psychological, social, and spiritual health, as well as their environment and preferences. The nurse may use various methods of data collection, such as observation, interview, physical examination, laboratory tests, and medical records.
2. Analyzing data: The nurse analyzes the data to identify patterns, trends, gaps, and inconsistencies. The nurse compares the data with the normal or expected values for the patient’s age, gender, and condition. The nurse also considers the patient’s strengths, resources, and coping skills.
3. Identifying problems: The nurse uses the data analysis to formulate a nursing diagnosis that describes the patient’s health problem or need in a concise and precise statement. The nurse may use a standardized classification system, such as NANDA-I (North American Nursing Diagnosis Association International), to ensure consistency and accuracy. A nursing diagnosis usually consists of three components: a problem label, an etiology (or cause), and defining characteristics (or signs and symptoms).
4. Planning care: The nurse develops a nursing care plan that specifies the goals, interventions, and expected outcomes for the patient’s care. The goals are measurable, realistic, and patient-centered statements that describe what the patient will achieve or maintain as a result of the nursing interventions. The interventions are actions that the nurse will perform or delegate to others to address the patient’s problem or need. The expected outcomes are criteria that indicate whether the goals have been met or not.
An example of a nursing diagnosis and care plan for a patient with pneumonia is:
Nursing diagnosis: Ineffective breathing pattern related to inflammation of lung tissue as evidenced by dyspnea, tachypnea, crackles, and hypoxia.
Goal: The patient will maintain adequate oxygenation and ventilation.
Interventions:
– Monitor vital signs, oxygen saturation, and respiratory rate and rhythm.
– Administer oxygen therapy as prescribed and adjust flow rate according to oxygen saturation level.
– Position the patient in semi-Fowler’s or high-Fowler’s position to facilitate breathing.
– Encourage deep breathing and coughing exercises to mobilize secretions.
– Provide chest physiotherapy and suctioning as needed to clear airways.
– Administer antibiotics and analgesics as prescribed to treat infection and pain.
– Educate the patient about the disease process, prevention measures, and self-care strategies.
Expected outcomes:
– The patient will have normal vital signs and oxygen saturation within the normal range.
– The patient will report relief of dyspnea and pain.
– The patient will demonstrate effective breathing pattern with no crackles or wheezes.
– The patient will be able to perform activities of daily living without difficulty.
Works Cited
Ackley, Betty J., et al. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. 12th ed., Elsevier, 2019.
Carpenito-Moyet, Lynda Juall. Handbook of Nursing Diagnosis. 15th ed., Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017.
Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. 10th ed., F.A. Davis Company, 2019.
