You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions, and incorporate the knowledge that you have gained into your patient’s care plan.

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A care plan is a document that outlines a patient’s current health status, identifies nursing diagnoses and problems, establishes goals and outcomes, and lists nursing interventions to address the patient’s needs. Care plans are designed to help patients receive coordinated, holistic care.

Nurses should use the five-step nursing process when developing care plans. These steps include assessment, diagnosis and planning. These are tips to help you get through each stage of the nursing process.

  1. Assessment: Gather information about the patient’s health status, including physical, psychological, and social factors.
  2. Diagnose: Use standardized terminology to identify nursing problems and diagnoses based upon the assessment data.
  3. Planning: Establish goals and outcomes for each nursing diagnosis and problem, using measurable criteria and considering the patient’s preferences and values.
  4. Implementation: Implement nursing interventions to address each nursing diagnosis and problem, using evidence-based practices and considering the patient’s individual needs.
  5. Evaluation: Evaluate the effectiveness of the nursing interventions, and revise the care plan as needed based on the patient’s response.

The care plan should incorporate patient-centered, shared decision-making and patient-centered care. In order to plan care, nurses should be involved with the patient’s family, setting goals and outcomes as well selecting the interventions. The care plan should also consider the patient’s cultural, religious, and social needs to provide personalized and holistic care.

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