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Nursing diagnosis, goals and interventions are important parts of the nursing care plan. A nursing care plan summarizes the care a patient will receive from a nurse. It reflects the nursing process encompassing five steps: assessment, nursing diagnosis, planning, implementation and evaluation. Goals and interventions are identified in the planning stage. While the nursing process is listed in steps, it is cyclic and continuous.
Form the nursing diagnosis. The nursing diagnosis is a statement you make about the patient based on an actual problem or risk. It is not a medical diagnosis, however. The nursing diagnosis relates the patient's response to illness. Examples of nursing diagnosis are: "At risk for impaired skin integrity related to (R/T) limited mobility," "nausea R/T chemotherapy treatments," and "sleep deprivation R/T acute pain." List these in the nursing care plan.
Prioritize the nursing diagnoses. Nursing diagnoses are prioritized according to the level of importance. Rank each one as follows: highest, moderate, lowest. Highest priorities relate to problems with breathing and airway management, the circulatory system and body temperature. Lower level priorities can be put off until all others have been dealt with. These are not immediate needs. Lower level priorities can possibly be delegated. Priorities may also be ranked using numbers with "1" being the top priority.
Establish expected outcomes for the patient. Write an expected outcome for each nursing diagnosis. Examples are: "The patient will go to physical therapy daily," "The patient will report pain relief non-verbally by use of pain scale," "The patient will be free of infection." Each outcome should be focused on the patient and have a target date for completion.
Develop your nursing interventions. Nursing interventions are what you plan to actually do for the patient to help him achieve the expected outcomes. Examples of nursing interventions are: "Suction patient every 2-4h as needed," "Administer antihypertensive medication as ordered," and "Assist with activities of daily living." Write the nursing intervention next to each goal listed on the plan.
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