Rationale and Nursing Intervention

Nurses who know the rationale:

1. Better able to plan the nursing care of their patients

2. Able to safely adapt nursing care to new situations, new equipment and
changing technology
Example:
 Anticipate need for analgesics or additional methods of pain relief.
Prevention is one way of dealing with pain effectively. Early intervention
may decrease the amount of analgesia required.
 Instruct the patient in the use of one or a combination of following
techniques;
a. Imagery
b. Distraction Techniques
c. Massage of affected area when appropriate

The Nursing Care Plan

Purposes:

1. As guide for patient – centered or individualized care

2. As an indicator of the goals of nursing intervention
3. For continuity of care
4. For effective communication
5. As basis for evaluating nursing care
6. As guide for supervision
7. As basis for discharge planning
8. As legal basis for professional practice

Criteria for Developing the Nursing Care Plan

1. The nursing care plan is initiated on admission

2. It is done in writing as part of the patients permanent record
3. It is based on specific problems and needs of the patient
4. It is coordinated with the medical plan of care.
5. It indicates specific nursing measures to be taken which are based on
therapeutically effective scientific principles
6. It ensures maximum physical and emotional for the patient
7. It reflects immediate and long range planning
8. It identifies and meets psychological and physiological needs of the
patient
9. It provides for family and patient participation as much as possible
10. It includes teaching programs in discharge planning
11. It specifies objectives, methods and approaches
12. It is updated daily
 Writing the Nursing Care Plan

The most simple is the four - column plan which shows the date when the
nursing diagnosis was made; the nursing diagnosis which includes the related
factors and defining characteristics; the goals or expected outcome; and the
nursing interventions that include on-going assessment, therapeutic
interventions, and health teaching

NURSING CARE PLAN

Date Nursing Expected Nursing Interventions

Diagnosis Outcomes Assessment, Therapeutic
Interventions
March Ineffective To establish a  Auscultate Chest for character
15,2005 Breathing normal effective of breath sounds, presence of
Pattern respiratory secretions
Related To pattern  Note type of breathing pattern
Alteration of (Tachypnea, Cheyne- Stokes
Normal are other irregular patterns)
Oxygen  Administer oxygen @ lowest
Ratio concentration as indicated for
respiratory distress or cyanosis
per doctors order
 Suction secretions as needed
 Elevate head of the bed to
promote physiologic/
psychological feeling of
manual isnpiration

Discharge Planning

Discharge Planning begins when the nursing diagnosis is made.

Discharge Planning Worksheet

A. Discharge Planning Given to:

B. Diet
C. Medications
D. Treatments
E. Activity Level
F. Follow-up Care
G. Actual Discharge