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Tuesday, November 16, 2010

How to make an NCP? Nursing Care Plan

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How to make an NCP?
First thing that you need to do when making an NCP is to go through the assessment data you have been given about this patient.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written nursing care plan NCP:

A - Assess (what is the situation?)
D - Diagnose (what is the problem?)
P - Plan (how to improve/stabilize the problem)
I - Implement (putting plan into action)
E - Evaluate (did the plan work?)

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) . The nurse completes an holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data.

2. Diagnosis - Nursing Diagnosis represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient’s assessment.

3. Planning - In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome.

4. Implementation - The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established.

5. Evaluation - The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly.
Now some schools uses the SOAPIE method, if you would like to download a sample SOAPIE NCP format, click here SOAPIE NCP

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