Nursing Care Plan: What You Need to Know

Nursing Care Plan: What You Need to Know

by | Sep 23, 2023 | Nursing Student

Nursing Care Plan: What You Need to Know

A nursing care plan is essential to student nurses and nurses alike. It is the basis of patient care and helps understand the patient’s condition. How can you write an effective nursing care plan? 

 

What is a Nursing Care Plan?

A nursing care plan is a plan that contains relevant information about the patient’s diagnosis, goals of the treatment, and specific nursing orders. It also contains the evaluation plan and actions that must be performed on the patient. 

The nursing care plan is also updated throughout the patient’s stay—any changes in the patient or if there’s new information added to the plan. In some hospitals, nurses must update their care plan during and after the shift to see improvements. 

 

The Purpose

The nursing care plan aims to help define a specific patient’s nursing guidelines and treatment. It is a plan that helps guide nurses throughout their shift in caring for their patients. It also allows nurses to give their patients focused and attentive care. 

 

What Makes up a Nursing Care Plan?

There are several components used in a care plan. These include the following:

  • Nursing Diagnosis – this is a clinical judgment that helps nurses develop a care plan for their patients.
  • Expected outcome – is a measurable action plan for a patient to achieve within a specific time frame. 
  • Nursing interventions and rationales – are actions to be taken to achieve the expected outcomes and reasons behind them. 
  • Evaluation – is how you determine the effectiveness of the care plan and see if the expected outcomes are met within the said time frame. 

These components are essential to the overall nursing care plan and process. A good nursing care plan must have these sections, or it will not make sense:

 

4 Types of Nursing Care Plans

There are many ways to write a care plan. Memorizing how they help you is essential. Here are the four types:

  • Informal – is a care plan that exists in the nurse’s mind. The action plan for this care plan is what the nurse wishes to accomplish during their shift. 
  • Formal – a type of care plan that is written or computerized. It is organized and coordinates with the patient’s care information and plan.
  • Standardized – is nursing care for a group of patients with the same everyday needs. 
  • Individualized – is a care plan tailored to a specific patient’s needs. 

 

How to Write a Nursing Care Plan

One of the first things you need to determine before writing a nursing care plan is to see the problems affecting the patient. What are the medical problems that affect them? Not just the medical problems but the psychosocial problems as well. 

Once you have listed the problems affecting the patient and the corresponding nursing diagnosis, you can determine the essential ones. Consider the ABCs or the Airway, Breathing, and Circulation to determine this. However, these will not always be the basis or be relevant to your patients. 

 

Step 1 – Assessment

To determine your care plan, always assess your patients first. It means you must gather subjective and objective data from your patients. 

Subjective data is what the patient has verbalized. It could be symptoms, feelings, perceptions, and even their concerns. 

Objective data is the information you’ve gathered based on observation. These are often measurable and can come from:

  • Vital signs – blood pressure, respiratory rate, heart rate
  • Verbal statements of the patients and their family
  • Physical complaints – for example, headache, pain, nausea, vomiting
  • Body conditions – assessing the patient from head to toe
  • Medical history
  • Height and weight
  • Intake and output
  • Patient feelings, concerns, perceptions
  • Laboratory data
  • Diagnostic testing – like X-ray, EKG, echocardiogram etc.

 

Step 2 – Diagnosis

A nursing diagnosis best fits the patient’s condition, objectives, and goals for the individual’s hospitalization.

The North American Nursing Diagnosis Association or NANDA, “a nursing diagnosis is a clinical judgment about the human response to health conditions, life processes, or a vulnerability for that response by an individual, family, group, or community.” 

Nurses can also formulate a diagnosis based on Maslow’s Hierarchy of Needs. With this, nurses can formulate a treatment plan and prioritize them. It also helps determine their next step. 

 

Types of Nursing Diagnosis

There are four types of nursing diagnoses that you can do. These are:

  • Problem-focused – the diagnosis is based on the problem present in the patient. 
  • Risk – includes the risk factors nurses see that require intervention from them and the healthcare team before a real problem develops.
  • Health promotion – aims to improve the general well-being of the patient, their families, and/or community. 
  • Syndrome – occurs in a pattern or can be addressed through the same nursing interventions. 

Once the nurses determine the diagnoses, they can begin their nursing diagnosis statement. There are three main components of a nursing diagnosis. These are:

  • Problem and its definition – refers to the patient’s current health problem and the nursing interventions needed.
  • Risk Factors or etiology – are the possible reasons behind the problem or the contributing factors that led to the patient’s condition. 
  • Defining characteristics – are the signs and symptoms that allow the specific diagnostic label in the place of defining characteristics for risk nursing diagnosis. 

 

Step 3 – Outcomes and Planning

Once you have your nursing diagnosis, create a SMART goal based on evidence-based practices. SMART goals are:

  • Specific
  • Measurable
  • Achievable
  • Relevant
  • Time-bound

It is also best to consider the medical diagnosis of the patient and overall condition for your data collection. Consider the goals you want to achieve for this patient and the short- or long-term outcome. It should be realistic and something the patient wants to do. 

 

Step 4 – Implementation

After setting all the goals, implement them to help your patient achieve them. Some actions will have immediate results; others may be seen later during hospitalization. During the implementation phase, you will be performing your nursing care plan. 

Your care plan must include the patient’s family, behavioral and physiological aspects, community, safety, health system interventions, and complex physiology. 

Some interventions implemented are diagnosis or patient-specific, but several can be completed within a shift. These are:

  • Pain assessment
  • Position changes
  • Fall prevention
  • Providing cluster care
  • Infection control

 

Step 5 – Evaluation 

The last part of your nursing care plan is the evaluation phase. It is where you evaluate the outcome of your care plan and see if the goals are met during the shift. The possible outcomes are met, ongoing, or not met. 

The evaluation can determine if the goals and interventions need improvement. Ideally, these goals must be met by the time of discharge.

However, it is not always the case, especially if the patient is discharged to home care, hospice, or long-term care facility. The outcome of your goals always depends on the patient’s condition. 

It would be best to choose achievable nursing goals that the patient can do. It will also help the patient feel that they have accomplished something and are progressing toward recovery. 

 

Takeaway

Nursing care plans are essential in patient care. They are your guidelines for your patient’s progress. You must learn to write one and implement your care plan each shift. It will help you polish your nursing skills as you learn how to care for your patient.

Hopefully, this post helped you; good luck!

 

Looking for more student resources? Check out these helpful links!

6 Travel Nursing Positions with the Highest Pay

6 Travel Nursing Positions with the Highest Pay

by | Jul 1, 2023 | Travel Nursing

6 Travel Nursing Positions with the Highest Pay

Working as a travel nurse is one of the most liberating areas of nursing. You can choose the areas you want to work in and even enjoy the benefits of financially lucrative travel nursing positions.

If you are interested in becoming a travel nurse, get to know which areas pay the most.

Nurses can choose almost any specialty area to work in, in the travel healthcare sector. As travel nurses, you will be making more than a staff position in a position or specialty.

It is wise to select from some of the highest-paying nursing specialties. 

1. Intensive Unite Care Nurse or ICU Nurse

One of the most in-demand areas for travel nurses belongs to the ICU. If you have experience in this department, you are in luck, as many hospitals use nurses in the ICU to float around other units because of their broadened skills and knowledge.

It makes them valuable members of the team.

ICU nurses are trained to care for the critically ill and have a broad array of skills. As a travel nurse, you too can work in this area as long as you have the skills or experience of an ICU nurse. Most facilities look for at least 1-2 years of experience.

2. Labor and Delivery Nurse 

Nurses specializing in obstetrics and women’s health, especially in antepartum and postpartum care, are constantly in-demand. L&D nurses are also among the highest-paid nurses in the country and one of the travel nursing positions with the highest pay.

However, before you sign the contract, consider a few things first. While you will be taking care of healthy patients in this area, you must be ready to handle any emergencies that could occur.

These may include emergency C-sections and many others. If you are up for the challenge, then this could be a fantastic opportunity for you. 

3. Emergency Room or ER Nurse

Do you enjoy a fast-paced environment while working as a nurse? If you do, then working as an ER nurse is the best place for you.

Many travel nurses can work in this department and earn more pay than their staff job.

Remember that working in the ER means you have to constantly use your critical thinking skills, so if you love solving problems, this could be the right place for you.

When looking for an ER position, it is always good to look at the hospital trauma level, it may be more acute than your used to.

4. Pediatric Intensive Care Unit Nurse or PICU Nurse/ Neonatal Intensive Care Unit or NICU

As a travel nurse, you will have the chance to work with some of the latest technology used in childcare, with plenty of nursing opportunities in states like Texas, New York, New Jersey, California, and many others. 

5. Medical-Surgical/Telemetry Nurse

The need for nurses with exceptional skills and knowledge in medical-surgical nursing is in demand these days. Since the number of Covid patients is still elevated, there is always a need for nurses in this area.

Travel nurses can apply for this position and earn up to  $5,000/week. If you are a nurse who can handle several patients and can manage time effectively, this could be an excellent opportunity to take.

6. Operating Room Nurse or OR Nurse

One of the most interesting areas and travel nursing positions with the highest pay belongs to the Operating Room.

You will be a valuable asset to many hospitals across the country for travel nurses with perioperative skills.

If you are certified at a specific OR skill or have a wide range of operating room experience, t you can snag any  OR position, 

In Closing

Consider also the location of the place for your travel nursing assignment. Some states pay higher than others. Now that you know which areas pay travel nurses the most, find a good agency that can get you a position in these areas.

It is also an excellent option to do more research on travel nursing before asking for an assignment. That way, you know what to expect and still earn more than staff. 

 

Looking for more nursing and travel nursing information? Check out these helpful links!

EP 219 – The Current State of Travel Nursing

EP 219 – The Current State of Travel Nursing

by | Jun 9, 2023 | Podcast

The Current State of Travel Nursing

Amidst the widespread infection, healthcare providers such as hospitals, private practices, and clinics faced significant challenges in acquiring essential resources beyond just personal protective equipment (PPE) and masks. The surge in demand for nurses and other healthcare professionals during this time led to an increased necessity for travel nurses. This unprecedented demand further resulted in remarkably high salaries for travel nurses.

Travel Nurse Salary Temporary increase

According to data from Vivian Health, travel nursing salaries reached nearly $3,500 per week by December 2020. However, the peak occurred approximately a year later, with rates soaring to nearly $4,000 per week. Between January 2020 and December 2021, the average pay for travel nurses experienced remarkable growth of over 99%. From December 2022 onwards, travel nursing salaries began to stabilize at approximately $3,100 per week.

Where did the increase in nurse pay come from?

The higher pay for nurses didn’t come out of nowhere. It didn’t magically occur out of thin air. Keep in mind that most hospitals are for-profit so they like to keep their labor costs low and maximize their revenue. Most hospitals wouldn’t have raised their pay nearly as much is they weren’t getting funding from somewhere. 

  1. Federal funding: one-way hospitals had money was through the Allocation of Provider Relief Fund.
  2. PPP Loans: Federal Government loans that didn’t need to be paid back. 
    • Hospitals received about $68 Billion from the initial PPP loans and then another $29 Billion for the second distribution. 
  3. Extra State funding: Besides Federal money being given to healthcare facilities States also increased their budgets and gave hospitals more funding. 
    • Illinois: The overall healthcare budget for Illinois was increased by about $250 Million for hospitals
      • Safety Net Hospitals (24): Funding increased $81.4 million
      • Critical Access Hospitals (51): Funding increased $14 million
      • High Medicaid Hospitals (30): Funding increased $86 million
      • General Acute Hospitals (69): Funding increased $62.1 million
      • Psych Hospital (10): Funding increased $2.4 million
      • Long-Term Acute Care Hospitals (6): Funding increased $1.2 million
      • Rehab Hospitals (4): Funding increased $2.3 million
      • https://www.illinois.gov/news/press-release.21790.html 

Decrease in Travel Nurse Pay

There has been an overall decrease in travel nursing pay and even an overall decrease in travel nursing contracts. What is driving this change and what is pushing the cost for nurses down?

  1. Less Government funding
    • The main factor for the decrease in travel nurse pay is a decrease in government money. Hospitals aren’t going to hire more nurses if they don’t need to even though the employees do. That’s exactly why there are no nationwide ratios. 
    • In 2023 according to Macrotrends hospitals are having some of the lowest profit margins since 2016 but are overall up from 2022.
    • https://www.macrotrends.net/stocks/charts/HCSG/healthcare-services/net-profit-margin  
  2. Are there fewer jobs?
    • According to government projections (US Bureau of Labor and Statistics), an estimated annual increase of over 203,000 registered nurse positions is expected to be generated between the years 2021 and 2031.
    • According to Indeed, states like California, Texas, New York, Florida, and Pennsylvania each have over 150,000 – 320,000 new RN positions opening each year. 
    • There are 290,000 Registered positions posted on Indeed. According to Vivian, there are 83,000 travel nurse positions available. 
    • https://www.indeed.com/career-advice/finding-a-job/how-many-jobs-are-available-for-registered-nurse 
    • There are no fewer jobs. People are always getting sick. Go to your local Walmart and you can see all the comorbidities. Nurses are needed everywhere. 
  3. Seasonal changes
    • Always keep in mind that nursing has multiple specialties and each specialty peaks at different parts of the year. For example in the warmer months as the season changes pediatrics gets hit harder because children start to get respiratory issues and the OR trends up because people tend to get more surgeries in the warmer months. 
    • During the winter months, there is a peak in older people getting sick so specialties like ED and ICU tend to get busier. 
  4. Staff incentives
    • There has also been an increase in incentives for staff nurses. Incentives such as higher sign-on bonuses if you stay an X amount of years. There are also nits that offer pick-up bonuses of a couple of hundred dollars extra per shift. 

Overall State of the Travel Nursing Market

This happens every year. I’ve been travel nursing for the last 3 years and a year before the pandemic and this was always the talk of the summer. Travel nursing is always going to give you higher pay than your staff job done in the right way. Same way you can get screwed as a staff nurse you can get skewed as a traveler if you don’t do your homework. Travel nursing is not going anywhere prices are just stabilizing from the all-time highs seen in the last few years. There is also another trend rising which is PRN nursing. 

If you want to learn more about travel nursing check out this link: https://cupofnurses.com/becoming-a-travel-nurse-get-to-know-your-dream-job/

Watch the full episode: https://youtu.be/uWS0r2d1Qsk

EP 212: A Patient’s Perspective of Delirium With Amelie Susanne

EP 212: A Patient’s Perspective of Delirium With Amelie Susanne

by | Apr 21, 2023 | Podcast

EP 212: A Patient’s Perspective of Delirium With Amelie Susanne

What is a patient’s perspective of delirium? An induced coma is also known as MIC or medically induced coma, barbiturate-induced coma, or drug-induced coma.

It is also called as temporary coma or a deep state of consciousness controlled by an anesthetic drug.

Often, barbiturates like pentobarbital or thiopental are used to help patients. It can also be intravenous anesthetic drugs like midazolam or propofol, but what happens when a patient goes through an induced coma and wakes up from it?

Can a patient recall any memory while they are in a coma? This episode will talk about a patient’s perspective of delirium and many more. 

In this episode, we would like to introduce you to Amelie Susanne Roth. Susanne is a coma survivor. After an initial bacteria infection, Susanne had to be placed into an induced coma that lasted 16 days.

We talk about her time in the ICU and her experience of being in a coma and suffering from it. In this episode, we flip the script and learn firsthand about the patient’s experience.  

 

Questions for Our Guest

The questions below are some we’d like to tackle. We often go off-topic, so we don’t expect to hit them all. If you have any ideas, please let us know.

Looking forward to our conversation!

These are the questions you had in Calendly. We’ll go off our questions, and wherever else our conversation goes.

  1. Please give us a little background about yourself.
  2. How did you end up in the hospital? And can you go a little in-depth into what happened?
      • Do you know what kind of infection it was? Where it came from?

3. Can you put us through the course of your hospital experience? Before this, coming from the day you came in?

      • What you heard, what were you told, and how did you feel?

4. You going into a coma and being intubated; was this something you expected? 

5. When you were intubated and unresponsive, what was happening? 

      • Do you remember any of it? 
      • How did it feel?
      • Were you able to hear anything?
      • Was it just like a dream state?

6. When you came out of the coma, were you mentally back to normal?

      • Were you aware of the whole extubation process? For example, when nurses say, can you open your eyes, squeeze my hand, weaning process?
      • Did you suffer from any delirium or confusion?
      • How did you feel during everything that was going on?

7. Where do you think healthcare providers can improve?

8. What was the process after you regained consciousness?

      • Did it take you a long time to bounce back? PT/OT? What does PT/OT mean?

9. How has life changed for you?

      • Additionally, did you have any big realizations? Like a change in mentality or outlook? 

10. What made you decide to write a book?

 

Ending Questions

Before we end the show, we have one last question we like to ask all our guests.

If you had the opportunity to have a Cup of coffee with anybody one last time, who would it be and why? 

 

Links: 

www.ameliesusanneroth.com
https://a.co/d/efqtaHD

Do you want to learn more about a patient’s perspective of delirium? Watch the full episode here 👇👇

TIMESTAMPS:

00:00 Introduction
01:32 About Amelie Susane Roth
02:38 How it all started
07:25 Experiences of Being Under Sedation and in a Coma
13:40 How does it feel to be in delirium or a coma?
15:57 A better understanding of why a patient gets agitated
18:14 The post-coma experience
25:03 Medicine Failing Patients and the Need for a Different Approach
27:50 Coping with Traumatic Experiences After a Coma
35:00 Life’s outlook after coma
40:48 Amelie’s life prior to becoming a patient
44:27 The Life Lessons While Traveling The World
47:18 Wrapping up the show

5 Tips to Effectively Earn Your Patient’s Trust

5 Tips to Effectively Earn Your Patient’s Trust

by | Apr 15, 2023 | Nursing

5 Tips to Effectively Earn Your Patient’s Trust

How do you earn your patient’s trust? Earning our patient’s trust is vital to us nurses. We can provide them with the best nursing care if they trust us.

But how can we gain our patient’s trust? Is there a magic word to use? 

 

Every Patient is Different

Not all patients are the same. They all have different personalities, moods, and preferences. Sometimes, it’s hard to guess what kind of mood our patients are in, especially when they’re in pain for some time. 

As nurses, we must adjust our personalities to our patients. We cannot be angry or grumpy when the patient screams at us.

We have to be firm but gentle towards them at the same time. Seeing them beyond their pain and complaints is the first step to earning their trust. 

So how can we gain our patient’s trust? Here’s how

 

#1. Introduce yourself and address your patient by their name

The first thing you must do in building any relationship is to introduce yourself. An introduction is an obvious thing to do, especially in a healthcare setting where you care for different patients. Just like building a relationship, an introduction is the first step.

However, introducing yourself to your patient is sometimes forgotten in a busy healthcare unit or setting. But remember that you will be the patient’s first point of contact for their concerns, calls for help, or inquiries.

It is vital that they feel like they know you and are receiving personal care from you. We cannot always remember every patient’s name, so an initial introduction is crucial. 

Introduce yourself and shake your patient’s hand. Tell them your name and who you are. Ask them what they prefer to be called and take note of this on their chart.

It will ensure a consistent level of care even when staff changes. It will also help the patient feel at ease, knowing they have someone to call if needed. 

 

#2. Always dress professionally

You’ve probably heard the phrase, “First impressions always last.” This phrase is accurate, so how your patient sees you is essential. How you introduce yourself is one thing, but how you show up is another.

As nurses, we must dress appropriately. Wearing a nurse’s uniform is one way, as most people will think that a person wearing that uniform has the proper training and knows what they’re doing.

But make sure that your scrubs or uniform are clean and pressed. It will create the right impression. Avoid showing up in your patient’s room with blood-stained scrubs or drenched in puke or body fluids.

Your patients may not be comfortable with you and may not cooperate with you at all. Always keep your appearance as positive as possible. 

 

#3. Listen to your patients.

Going in and out of your patient’s room is easy, especially when you’re taking their vital signs. You can mutter a few words while writing information on their charts but earning your patient’s trust is more than that. If you want to build trust:

  1. Talk to them.
  2. Make eye contact and actively listen.
  3. Ask questions, and converse with them.
  4. Pay attention to your body language, sit in front of them, and make it clear that they have your attention. 

Sometimes, taking a break from your usual nurse routines and being present with the patient. Take time to hear them out and listen to them express themselves.

When a patient knows they’re being listened to will make them feel confident that their concerns are addressed. That makes them trust you as their nurse. 

 

#4. Keep your word

It’s tempting to comfort a distressed patient by telling them that things will be okay. However, you must make sure that you act with integrity and honesty at all times.

Patients and their families appreciate honesty even though your honesty can sometimes be hard to accept. Avoid making false promises. Keep your word by following through with what you tell your patient. It is one of the best ways to earn their trust. 

You don’t have to promise anything significant. Following through with simple acts can help your patient feel they can rely on you. If you say you’ll be back in an hour, then be back in an hour.

Again, keep your word. If you can’t guarantee this, tell them you’ll likely be called away to an emergency or other tasks. Again, don’t make any promises you can’t keep. 

Our work demands are unpredictable, especially in a busy healthcare setting. If this happens, ask someone to speak with your patient, maybe another colleague familiar with your patient, and keep them updated on what is happening. These are a few ways to earn your patient’s trust. 

 

#5. Be Trustworthy

To be trusted means you have to be trustworthy too. Being open and honest with your patient is one step. And even when the situation is unfavorable, keeping your honesty is a must.

Your honesty may not always be a comfortable place to be in, but your patients and their families will appreciate it. 

Always keep your word, and do not promise anything you can’t do. When your patients trust you, building a relationship with them can help improve their recovery time, making administering treatment more manageable.

Therefore for your patients to trust you, you must also put in the effort and show them that you’re genuine with your intentions to help them. 

 

Looking for more nursing and travel nursing information? Check out these helpful links!