BURAIDAH C ENTRAL H OSPITAL

Department : NURSING SERVICE Policy Index : PP-BCH-NR/GNR-033-DPP-E Title: NURSING CARE PLAN Applies to: All Nursing Staff New Replace Number :

B. C. H.

DPP

XXXXX

Effective Date: 01-01-1432 H

Number of Pages : 3 Review Due: 01-12-1433 H

1. PURPOSE : 1.1
1.2 1.3 1.4 To outline the nursing care to be provided to a patient. To provide each patient with individualized plan of nursing care. To determine priorities for nursing action. To aid the nursing staff in performing nursing activities in goal directed manner.

2. DEFINITION :
2.1 It is a set of actions the nurse will implement to resolve nursing problems identified by assessment.

3. POLICY: 3.1. It focuses on actions, which are designed to solve or minimize the existing problem. 3.2 All patients who stayed in the hospital more than 24 hours must have an individualized nursing care. 3.3 The written care plan must include input from Physicians, other health care disciplines and nursing assessment. 3.4 Review of the patient care plan must be done every shift and when any sufficient changes in the patients condition occurs. 3.5 Review of the patient care plan shall be done when new treatments are added or discon tinued.

Prepared by: Magdalena Venzuela Nurse Supervisor

Approved by: Ahmad Abdulla Al - Omar Hospital Director

Page Number: 1/3

Approval Stamp

Form Index: BCH-QM-009-E

4. PROCEDURES : 4.1 Gather and record datas based on nursing problems, complaints presented by patient. 4.2 Document patient needs / problems : 4.2.1 Identifies and prioritized patient needs both actual and potential.

4.2.2 Document those needs in the plan of care for 24 hours in the Nurses Notes. 4.3 Planning Patient Care : 4.3.1 Formulation of plan of care shall reflect current standard of care. 4.3.2 The plan of care shall include : 4.3.2.1 Actual and potential problem / needs which are identified based upon Assessment / Re - assessment and are designated as long or short term. 4.3.2.2 Potential problems / needs which the patient has a high risk for developing signs and symptoms are not present. The problem / need list. 4.3.3 Direct nursing intervention (nursing actions / orders) which include actions or a series of actions performed by the nurse and the client to prevent illness or its com plication and to promote, maintain or restore health. 4.3.4 Includes expected outcome / goal. These are statements of patient behaviour that would demonstrate an improvement in or resolution of the problem expected out come are measurable and specific. 4.3.5 Guide discharge planning, refers to measures intended to provide continuity of care includes home care coordination. 4.4 Implementation.: 4.4.1 It occurs when physicians orders are carried out. 4.4.2 Nursing orders are implemented. 4.4.3 Nursing interventions, patient observation and evaluation of patient responses are documented in the 24 hrs. nurses record. 4.5 Evaluation: 4.5.1 Determining the patients response to intervention and or progress, or lack of progress towards the goal. Document status of the outstanding outcome as the final step in evaluation.

5. FORMS AND EQUIPMENTS :

5.1 Nursing Care Plan Form.

6. REFERENCES :
6.1 Nursing Policy, Documentation Rules. 6.2 http / www. sh.ishhsc.educ.

7. APPENDIX :
7.1 N/A.
Policy Number: PP- BCH-NR/GNR-033-DPP-E Title: NURSING CARE PLAN Page Number : 2/3 Approval Stamp

Form Index: BCH-QM-009-E

8. APPROVAL :

Name Prepared by: Magdalena Venzuela 1.Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3.Manae Al-Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Nurse Supervisor Nursing Director QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-11-1431 H

Policy Number: PP- BCH-NR/GNR-033-DPP-E

Title: NURSING CARE PLAN

Page Number: 3/3

Approval Stamp

Form Index: BCH-QM-009-E