Nursing Care Plan
Similar to nursing research papers, care plans are some of the most common assignments in nursing college.
Note that writing a nursing care plan entails a formal process defined by accurate identification of existing needs and recognition of potential needs or risks.
Care plans are as well used as communication tools among nurses, other healthcare professionals, and patient and their families to help realize positive healthcare outcomes.
The care plans are intended to help enhance quality and consistent health care service delivery. Note that care plans start immediately after a patient admission and document all activities and changes in relation to the patient’s condition.
The plans play an important role in the delivery of patient-centered care. They are also used as a health care delivery evaluation tools.
Markedly, nursing care plans require essential skills on how to write assignment. Just like the case of PICO questions for nursing, nursing care plans should be anchored in evidence-based practice. [nbsp][nbsp]
- Nursing Care Plan
- Signs and Symptoms
- Nursing Diagnosis for Pneumonia
- Goals and Objectives of Nursing Care Plan for Pneumonia
- Key Components of a Nursing Care Plan for Pneumonia
- Steps for Writing a Nursing Care Plan for Pneumonia
Pneumonia occurs when pus or fluid is trapped in the lungs’ alveoli causing gas exchange impairment.
That noted, pneumonia can be classified into different categories. This classification is essential when developing a nursing care plan for pneumonia.
Such categories include:
1. Hospital-acquired pneumonia
HAP is pneumonia usually diagnosed after 48 or more hours of hospital admission.
2. Health-care acquired pneumonia
HCAP is pneumonia diagnosed within 90 days of hospital stay, long-term care facility stay, or nursing-home stay.
3. Community-acquired pneumonia
CAP is pneumonia contracted outside a health facility, in the community.
4. Ventilator-associated pneumonia
VAP pneumonia presents within 48 hours or more of endotracheal mechanical ventilation.[nbsp] [nbsp]
Signs and Symptoms
Signs and symptoms are essential when developing a pneumonia nursing care plan.
Common signs and symptoms of pneumonia include:
- Sputum production
- Shortness of breath
- Pleuritic chest pain
- Rapid shallow breathing
- Shaking chills
Nursing Diagnosis for Pneumonia
Common nursing diagnosis for pneumonia nursing care plans include:
- Impaired gas exchange
- Ineffective airway clearance
- Ineffective breathing pattern
- Acute pain
- Risk of infection
- Intolerance to activity
- Risk for imbalanced nutrition: Less than body requirements
- Deficient fluid volume risk
- Deficient fluid volume
- Deficient knowledge
Note that when writing a nursing care plan for pneumonia, you need to focus on each of the diagnoses separately.
In this, a nursing care plan for each diagnosis should entail components such as:
- Related factors
- Defining characteristics
- Desired outcomes and
- Nursing interventions
Goals and Objectives of Nursing Care Plan for Pneumonia
A formal nursing care should be guided by clear goal and objectives. Such goals and objectives are usually the basis for the evaluation function of the care plan. Per se, some of the goals and objectives of a nursing care plan for pneumonia include:
1. Augmenting holistic care
This objective focuses on providing health care that is inclusive of the spiritual, physical, social, and psychological elements of a human being.
It should seek to incorporate these elements in the prevention and management of pneumonia. [nbsp]
2. Enhancing evidence-based nursing care
This goal entails employing acceptable nursing knowledge in the treatment of pneumonia and creating appropriate and standardized conditions within hospitals and respective health care centers.
3. Developing appropriate health care programs
Concerning this goal, the care plan should seek to provide a good opportunity for the establishment of programs such as care bundles and care pathways.
While care bundles would focus on the care given to pneumonia patient, care pathways would look at the consensus by the treatment team members on care standards and expected outcomes.
4. Establishing methods of communication and documentation
This goal should acknowledge that communication is a critical element in an effective health care plan.
As such, you need to determine the most appropriate methods of communication between all respective stakeholders, including colleagues, other professionals, patients and their relatives, and the larger health care society.
5. Identifying health care goals
This objective involves outlining the goals to guide administration of the health care plan.
As earlier noted, the nursing care plan for pneumonia needs to develop specific goals to be used to assess clearly identified outcomes.
6. Assessing the care plan
This goal intends to use the nursing care plan as the primary tool for the assessment of the effectiveness in health care delivery.
As earlier pointed out, the plan should have clear goals and outcomes to evaluate the care plan.
Key Components of a Nursing Care Plan for Pneumonia
A nursing care plan encompasses different components. These components usually have a profound influence on the health care plan.
As such, it is important to understand the relationship between these components to help enhance health care delivery. Some of these components are as discussed below.
The assessment component focuses on the background information of the Individualized Health Care Plan (IHCP). It is the primary element in the design of an IHCP. It includes information on:
–Patient’s health history
–Patient’s current health status
–Entailed self-care needs/skills
–Patient’s psychosocial status
–Key health issues related to nursing education
2. Nursing Diagnosis
This component entails a summary of the patient’s current health status based on the nurse’s view of the patient’s health condition.
It as well reveals to the contributions of the nurse/students in real-life professional practice. It looks at your understanding of nursing issues and practice at an individual level.
3. Health Care Plan Goals
Care plan goals form the basis of nursing intervention. Such goals should encompass lucid, succinct, and realistic descriptions of expected outcomes.
It is essential that you clearly stipulate the goals to guide the care plan right from the beginning.
Such goals could be long-term or/and short-term. Importantly, they must be effectively measurable.
4. Nursing interventions
These entail all the treatments and procedures undertaken to help achieve a specific goal or realize a desired outcome.
The care plan should respond to all the conditions identified by the diagnosis.
Accordingly, they should be elaborate and specific enough to ensure that the condition is effectively addressed, and with appropriate precision.
5. Learning outcomes
This component entails a detailed description of what the nurse student or registered nurse is expected to do.
It looks at the actions and activities you are required to carry out in the intervention process.
You should clearly explain what you intend to have learned by the end of the health care plan. The outcomes should be realistic and easy to measure. [nbsp]
This component involves regular assessment of the student’/ nurse’s goals and outcomes. In doing so, the actual outcomes should be compared with the expected ones.
The interventions should be constantly reviewed and IHCP modified when and if necessary.
Note that assessment should also be carried out when there is a drastic change in the patient’s health status, or when there is a change in prescribed medications or treatment.[nbsp]
Steps for Writing a Nursing Care Plan for Pneumonia
Note that with the right skills, writing a nursing care plan is relatively an easy task. Per se, it is possible to write a nursing care plan in ten minutes.
This is equally the case with writing a nursing care plan for pneumonia. [nbsp]The writing process is systematic, where it is defined by specific steps. These steps include:
Step 1: Collecting data
This is the first step and requires you to develop a client database through effective assessment methods and appropriate data collection techniques.
This involves the use of tools and methods like diagnostic studies, physical assessments, review of medical history, and interviews.
The nurse can use the database to identify related risk factors and characteristics essential in developing a nursing diagnosis.
Step 2: Analyzing data
This step involves organizing acquired data to enhance its effective use. You should cluster the data to help arrive at patterns or models key to the formulation of nursing diagnosis, goals, priorities, and expected outcomes.
In this, you should use all available data/information and effectively consider its implications on the nursing care plan for pneumonia.
Step 3: Formulating nursing diagnoses
This step encompasses identifying, paying focus on, and handling client needs and responses in relation to entailed risks as well as high-risk problems.
Such diagnoses include nursing health problems that can be resolved or prevented using an independent nursing intervention.
Step 4: Establishing priorities
This step encompasses determining the preferential sequence of actions intended to address nursing diagnosis as well as interventions. It requires collaboration between the nurse and the patient to establish the diagnosis that require first attention.
Concerning prioritizing, diagnosis can be categorized as low, medium, or high priority. Life-threatening problems are in the high priority category and should be attended to first.
Usually, a nurse can use the Maslow’s hierarchy of needs model to prioritize the diagnoses. Some of the factors to consider when establishing priorities include client’s personal priorities, client’s health beliefs and values, urgency, and available resources.
Step 5: Determining client goals and preferred outcomes
This step requires the nurse and the patient to set goals for respective priorities in the nursing care plan for pneumonia.
Such goals describe what the nurse seeks to achieve through the implementation of identified nursing interventions.
These goals guide the nurse on how to plan interventions, provide evaluation guidelines, determine level of success, and motivate both the nurse and the patient.
Step 6: Selecting nursing interventions
This step involves deciding on the actions and activities the nurse should adopt in order to achieve the established goals. Such intentions should aim to eradicate or diminish the nursing diagnosis’ etiology. This entails mitigating patient’s risk factors.
Note that the nurse could opt for either independent, dependent, or collaborative interventions. The interventions should be defined by the below characteristics.
–Should reflect the patient’s beliefs, values, and culture.
–Should be appropriate and safe for the patient’s condition, health, and age.
–Should be aligned to existing knowledge in nursing and other relevant fields.
–Should be aligned to other therapies.
–Should be able to achieve with available resources and time.
Step 7: Providing rationale
This step entails establishing scientific explanations on why the specific nursing intervention was selected.
Although they are not explicitly revealed in the nursing care plan for pneumonia, they are essential in helping nursing students relate the identified intervention with respective psychological and pathophysiological principles.
Step 8: Evaluation
This step involves organized, continuous, and purposeful assessment of the realization levels of set goals or desired outcomes as well as the nursing care plan effectiveness.
The evaluation should help determine whether to continue, terminate, or change the selected intervention.
Step 9: Documenting the plan
In this step, the nurse should feed the care plan and the intervention process to the hospital records system. This is important in creating a patient medical record that can be reviewed in the future.[nbsp]