A nursing care plan contains all of the relevant information about a patients diagnoses the goals of treatment the specific nursing orders including what observations are needed and what actions must be performed and a plan for evaluation. The results of the x ray determine the patients plan of care meaning pneumonia treatment or not as a nurse it is important to monitor for s s of aspiration and to inform the doctor if you suspect aspiration has occurred so the team can assess the need for an x ray. A nursing care plan is a process that includes correctly identifying existing needs as well as recognizing potential needs or risks care plans also provide a means of communication among nurses their patients and other healthcare providers to achieve health care outcomes. Nursing interventions rationale assess conditions that can increase the patients level of fall risk such as history of falls changes in mental status sensory deficits balance medications and symptoms related to diseases. A nursing diagnosis is used to define the right plan of care for the client and drives interventions and patient outcomes nursing diagnoses also provide a standard nomenclature for use in the electronic medical record emr allowing for clear communication among care team members and the collection of data for continuous improvement in
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