8.2
Planung von Pflegemaßnahmen II
Ein Pflegeplan kann in zwei Formen präsentiert werden: Informell und formell. Informell ist ein Pflegeplan für den individuellen Gebrauch der Pflegekr…
Ein Pflegeplan kann informell oder formell sein. Ein informeller Pflegeplan ist eine Handlung im Kopf der Pflegekraft.
Ein formeller Plan ist eine schriftliche Blaupause für die Patientenversorgung. Es wird weiter in zwei Typen unterteilt.
Standardisierte Pflegepläne spezifizieren die Pflege von Patienten mit Routinebedarf, während individualisierte Pflegepläne auf die individuellen Bedürfnisse der Patienten ausgerichtet sind.
Die Pflegepläne werden auf der Grundlage der menschlichen Grundbedürfnisse, der Pflegediagnose und der medizinischen oder interdisziplinären Pflegepläne formuliert.
Fünf Formate des Pflegeplans sind:
Computergestützte Pflegepläne, eine elektronische Krankenakte, die dazu beiträgt, den Papierkram zu reduzieren und die Aufzeichnungsführung zu verbessern.
Schichtwechselberichte kommunizieren Informationen bei der Pflegeübergabe.
Der kritische Pfad liefert Informationen über den standardisierten multidisziplinären Versorgungsplan, um die prognostizierten Patientenergebnisse innerhalb des Zeitrahmens auszudrücken.
Concept Mapping organisiert Patientendaten grafisch, analysiert Zusammenhänge in den Daten und gibt einen ganzheitlichen Blick auf die Gesundheit des Patienten.
Schließlich hilft ein studentischer Pflegeplan dabei, Wissen aus der Pflegeliteratur anzuwenden. Er ist aufwendiger als der eigentliche Pflegeplan, der in Krankenhäusern verwendet wird.
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Q1: What is the difference between informal and formal nursing care plans?
An informal nursing care plan is an action in the nurse's mind, used for individual shift goals and not included in the patient chart. A formal nursing care plan is a written or computerized blueprint for patient care that organizes care systematically. Formal plans are further divided into standardized care plans for routine patient needs and individualized care plans tailored to unique patient needs.
Q2: What are the five formats used to organize nursing care plans?
The five formats include computerized care plans, which reduce paperwork and enhance record keeping through electronic medical records. Change of shift reports communicate information during nursing handover. Critical pathways provide standardized multidisciplinary plans with predicted outcomes within timeframes. Concept mapping graphically organizes patient data and relationships for a holistic health view. Student care plans help apply nursing literature knowledge and are more elaborate than hospital care plans.
Q3: How does Maslow's Hierarchy of Needs guide nursing diagnosis selection?
Maslow's Hierarchy of Needs aids in prioritizing nursing diagnoses and subsequent interventions based on patient needs. The nurse develops nursing diagnoses according to data collected during assessment, then uses this framework to determine which diagnoses require immediate attention. This ensures interventions address the most critical patient needs first.
Q4: What makes SMART goals effective in nursing care planning?
SMART goals are Specific, Measurable, Achievable, Relevant, and Time-Bound objectives created after selecting a diagnosis. These goals must align with patient desires and realistic circumstances. For example, if a patient prioritizes mental health over dietary choices, the care plan should reflect patient-centered goals rather than nurse-assumed priorities.
Q5: What happens during the implementation phase of a nursing care plan?
Implementation is when nursing interventions outlined in the care plan are executed. Some interventions show immediate results, while others may only be visible later in the shift or hospital stay. The nurse carries out the planned actions to address the patient's identified needs and work toward established goals.
Q6: How does a nurse evaluate whether nursing care plan goals were achieved?
Evaluation allows the nurse to assess intervention outcomes and determine if goals were met. SMART goals have three possible outcomes: met, ongoing, or not met. Based on evaluation results, the nurse decides whether goals and interventions need adjustment as the patient's care journey evolves.
Q7: How do standardized and individualized care plans differ in patient care?
Standardized care plans are pre-populated guides for specific patient populations, such as post-operative patients, specifying routine nursing care. Individualized care plans are tailored to each patient's unique needs and adjust as the patient care journey evolves. Both types are formal written or computerized plans that organize patient care systematically.