|NURSING DIAGNOSES – THE CARE PLAN
( A WALK THROUGH )
Nursing diagnoses and Care Planning are extremely important
in the daily care of every patient who is admitted to the hospital.
When a patient is admitted to the hospital or other Healthcare
facility, a history is taken from the patient or other responsible
Whether a patient is admitted to the surgical floor, ICU or ER, the
nurse does an assessment and documents findings. Vital signs
are also taken and recorded. The doctor also questions and
examines the patient and decides on a diagnosis based on patient
history, physical and signs and symptoms.
The Care plan for each patient is a reflection of the information
provided about the history and doctor’s diagnosis.
Nursing Kardex – is used by nurses to provide information
regarding patient problems and the plan of care.
Here are some examples(only) of what might be found on the Care
1) The Surgical patient-
Anxiety – related to surgery and family dynamics
Pain - potential for pain related to surgery
Dehydration- related to fluid/ blood loss related to surgery
Paralytic ileus – related to anesthesia and surgical intervention
2) The Stroke patient –
Altered LOC ( level of consciousness)- related to stroke
Impaired mobility – related to prolonged bedrest
Seizures – related to brain injury
Fall prevention – related to impaired mobility