The therapeutic nursing care plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
The Nursing Care Plan TNP is the nurse’s responsibility. She’s the only one who can inscribe information and re-evaluate the TNP during the course of treatment of the patient. This document is used by nurses, nursing assistant and they communicate the directives to the beneficiary attendants. The priority problems or needs are often the diagnoses of the patient and nursing problem such as wounds, dehydration, altered state of consciousness, risk of complication and much more.
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These diagnoses are around problems or needs that are detected by nurses and need specific interventions and evaluation follow-up. The nursing directives can be addressed to nurses, nursing assistants or beneficiary attendants. Each priority problem or need must be followed by a nursing directive or an intervention. The interventions must be specific to the patient. For example, patients with the problem ‘uncooperative care’ can need different directives. For one patient the directive could be: ‘educate about the pathology and the effects of the drugs on the health situation’; for the other, it could be the use of a directive approach.’ It depends on the nature of the problem which needs to be evaluated by a nurse.
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans help nurses, their patients, and other health care providers talk to each other so that good health care outcomes can be reached.
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A Nursing Care Plan includes the following components;
- Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental. Information is this area can be subjective and objective.
- Rationale for interventions in order to be evidence based care.
- Evaluation. This documents the outcome of nursing interventions.