Developing care plans for psychosocial nursing diagnoses. 1994

M L Heafey, and P A Edwards, and T F McLaughlin

In 1992, the Nursing Department Documentation Committee at Spaulding Rehabilitation Hospital decided to revise the process of and forms for documenting nursing diagnoses. A sub-committee developed a format for standardized nursing care plans and piloted its use on two patient care units. The unit nursing staffs selected a number of common nursing diagnoses and, using the new format, developed standardized nursing care plans for them. After refining the process based on this pilot, the development of care plans was extended to all patient care units. A collaborative partnership was then formed between interested Primary Nurses, the Psychiatric Clinical Nurse Specialist and the Nursing Practice Coordinator to focus on developing psychosocially-oriented care plans as well as physically-oriented plans. Although psychosocial diagnoses are less frequently identified in the assessment process and included in nursing care planning, they are still very important for providing comprehensive care. This article describes the process of developing and implementing psychosocial care plans. This article also describes the components of the standardized nursing care plans developed for four psychosocial nursing diagnoses.

UI MeSH Term Description Entries
D009733 Nursing Diagnosis Conclusions derived from the nursing assessment that establish a health status profile for the patient and from which nursing interventions may be ordered. Diagnosis, Nursing,Diagnoses, Nursing,Nursing Diagnoses
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D010347 Patient Care Planning Usually a written medical and nursing care program designed for a particular patient. Nursing Care Plans,Goals of Care,Plans, Nursing Care,Care Goal,Care Goals,Care Plan, Nursing,Care Planning, Patient,Care Plans, Nursing,Nursing Care Plan,Plan, Nursing Care,Planning, Patient Care
D010865 Pilot Projects Small-scale tests of methods and procedures to be used on a larger scale if the pilot study demonstrates that these methods and procedures can work. Pilot Studies,Pilot Study,Pilot Project,Project, Pilot,Projects, Pilot,Studies, Pilot,Study, Pilot
D011367 Professional Staff Committees Committees of professional personnel who have responsibility for determining policies, procedures, and controls related to professional matters in health facilities. Committee, Professional Staff,Committees, Professional Staff,Professional Staff Committee,Staff Committee, Professional,Staff Committees, Professional
D012046 Rehabilitation Restoration of human functions to the maximum degree possible in a person or persons suffering from disease or injury. Habilitation
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man

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