Nurses develop comprehensive care plans through a systematic process that involves:
- Gathering Data: Collecting information from various sources, including patient interviews, medical records, and diagnostic tests. - Identifying Problems: Using clinical judgment to identify patient problems and potential complications. - Setting Goals: Establishing short-term and long-term goals that are specific, measurable, attainable, relevant, and time-bound (SMART). - Selecting Interventions: Choosing evidence-based interventions that are appropriate for the patient's condition and goals. - Documenting the Plan: Recording the care plan in the patient's medical record to ensure that all team members are aware of the plan.
