Nurses can collect data about the patient's vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. The nurse stops administering intravenous Lasix and contacts the healthcare provider to discuss the patient's current fluid status. In that case, creating a nursing care plan helps the nurse to monitor the patient's blood pressure levels, to monitor the effectiveness of the interventions, and to communicate with other health professionals about possible complications. This collaboration is further enhanced with TigerConnect patient engagement software, which allows healthcare teams to include patients and their families in the conversation through a secure group message.
This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses removed that no longer have supporting evidence. With the right integrations, you can even automate parts of the care plan so that certain fields are automatically filled with information. Illness or condition diagnosed by a doctor or an advanced health care provider, such as a skilled nurse or physician's assistant. An easy way to remember the ADPIE is to think of it as a delicious cake that the nurse carefully prepares for the client's well-being. The main EHR providers have the functionality of the care plan integrated into their systems, with lists of diagnoses and nursing interventions.
Another example of independent nursing interventions is the therapeutic communication used by a nurse to help patients cope with a new medical diagnosis. When all members of a care team have access to all the information about the patient's needs and preferences, everyone is informed. Nurses are responsible for collecting and maintaining this data, although certified nursing assistants can help collect vital signs. Care plans include a combination of short- and long-term goals that are specific, measurable, and timely. If the results are concerning, it is the nurse's responsibility to notify the provider and verify the appropriateness of the prescriptions based on the patient's current state before implementing them.
This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for a nursing diagnosis. While drafting care plans at school can be a time-consuming task, mastering this information in nursing school will improve your competence and trust. It includes step-by-step instructions that show how to implement care and evaluate outcomes, and help you develop diagnostic reasoning and critical thinking skills.
