Basic vs. In-Depth
Nursing care plans can vary as to how much data they provide. Some may break it down into the bare minimum to get the data quickly and concisely recorded so that anyone who views it can see what has been done. Others may opt for a more in depth nursing care plan that includes all of the various details, conditions, actions taken, thoughts on it, etc. The right method really comes down to the nurse and team that is caring for the patient and what works best for them. Some teams may prefer to only record and see the critical details of the treatment so that they do not need to read through too much to get updated, whereas others may prefer a longer form.
What Should Be Included in a Nursing Care Plan
A good dialysis nursing care plan should include at least a few different sections, such as:
- Nurse Diagnosis – The nurse diagnosis should be a compilation of the conditions and issues that the patient is currently dealing with. This is done after a full assessment of the patient, including their physical and mental status, and even social or economic circumstances in some through assessments. In many cases, the diagnosis may also include an explanation or definition of the condition just to make it easier for those reading.
- Outcome and Goals – This is essentially just a list of goals and desired outcomes that will hopefully occur as the patient undergoes treatment.
- Nurse Interventions – Nurse interventions or orders are the actions undertaken in treatment of the patient. This can include dialysis in general, taking vitals, administering medication, and more.
- Evaluation – The evaluation portion will include data from the patient’s overall status and changes as they are treated. This can also include additional assessments of the patient throughout the duration to see if anything has changed. The evaluation portion is important, as it tells whether the patient is responding to treatment and if they are happy with it, and it can also indicate if any of the treatment protocol needs to be altered.
As mentioned above, the nursing care plan may include more than the above, but these are often the bare minimum. Additional sections could include nurse or other care team thoughts or things that they have noticed that could be relevant to the treatment, or more.
Looking for a Position as a Dialysis Nurse?
If you have considered dialysis nursing jobs, then we can help here at New Directions Staffing. We work with numerous healthcare facilities across the country and dialysis nurses are in high demand. Our primary goal is to find you a position that is rewarding and aligns with your goals. If you have any questions, feel free to give us a call at our South Carolina office at 843-284-0080 or at our Rhode Island office at 401-884-0572. Contact us today!