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> care plan
care plan
Assessment and Diagnosis
Gather patient history
Conduct physical examination
Review diagnostic tests and results
Identify patient strengths and weaknesses
Determine nursing diagnoses
Goals and Outcomes
Define short-term goals
Define long-term goals
Ensure goals are measurable and achievable
Align goals with patient values and preferences
Interventions
Develop nursing interventions
Prioritize interventions based on urgency
Include patient education as part of interventions
Collaborate with interdisciplinary team members
Implementation
Assign tasks to appropriate team members
Schedule interventions
Document care provided
Communicate with the patient and family
Evaluation
Assess progress towards goals
Modify care plan as needed
Document evaluation findings
Reassess nursing diagnoses and interventions
Follow-up
Schedule follow-up appointments
Ensure continuity of care
Provide resources for ongoing support
Review and update care plan regularly
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