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Writing an iHuman Care Plan Nursing Assessment

An iHuman care plan is a comprehensive and organized document that outlines the specific care and interventions required for a patient in the iHuman electronic health record (EHR) system. iHuman is a virtual patient simulation platform used for healthcare education and training.

  • Elements: The iHuman care plan includes relevant patient information, such as demographics, medical history, allergies, and current condition. It also incorporates assessments conducted, nursing diagnoses identified, goals established, interventions planned, and evaluations of the patient’s progress.
  • Purpose: The care plan is designed to provide a structured approach to patient care, ensuring that healthcare providers have a clear roadmap to follow in delivering safe and effective treatment. It helps promote continuity of care, collaboration among healthcare team members, and communication between shifts or different care settings.
  • Components: The iHuman care plan may include various components, such as nursing diagnoses, medical diagnoses, medication management, pain management, risk assessments, education and discharge planning, vital sign monitoring, and referrals to other healthcare professionals or services.
  • Format: The specific format and content of an iHuman care plan can vary depending on the institution, healthcare setting, and the patient’s unique needs. It is typically tailored to address the individual patient’s condition, treatment plan, and goals of care.
  • iHuman Care Plan Example: Robert Jones iHuman Care Plan

Review: Nursing Care Plans Writing Guide:

  • Overall, the iHuman care plan serves as a blueprint for nursing interventions, outlining the specific steps needed to improve the patient’s health and well-being.
  • It helps nursing students develop their critical thinking and clinical decision-making skills by providing them with an opportunity to apply their knowledge in a simulated clinical setting.

Key Components of an iHuman Care Plan for Patient Assessment

The key components of an iHuman care plan typically include:

  1. Patient Information: This section includes essential demographic information about the patient, such as name, age, gender, ethnicity, and relevant medical history.
  2. Assessment: Summarize the findings from the patient assessment, including vital signs, physical examination results, laboratory tests, and any other pertinent assessments.
  3. Nursing Diagnoses: Identify and document nursing diagnoses based on the assessment data. Nursing diagnoses are clinical judgments about actual or potential health problems that nurses can address through interventions. They provide a framework for planning and implementing patient care.
  4. Medical Diagnoses: Document the medical diagnoses provided by the healthcare provider or team. These diagnoses describe the specific medical conditions or diseases affecting the patient.
  5. Goals: Establish measurable and achievable goals for the patient. Goals should be specific, relevant, time-bound, and aligned with the patient’s needs and preferences. They provide a clear direction for the care plan.
  6. Interventions: Outline the nursing interventions and medical treatments planned to address the identified nursing and medical diagnoses. Interventions should be evidence-based and tailored to meet the patient’s unique needs. They may include medications, therapies, procedures, patient education, and referrals to other healthcare professionals or services.
  7. Evaluation: Regularly evaluate and document the patient’s response to interventions. Assess whether the goals have been met, partially met, or not met. Adjust the care plan as necessary based on the evaluation results.
  8. Medication Management: Detail the medications prescribed for the patient, including the medication names, dosages, frequencies, routes of administration, and any special instructions or precautions.
  9. Education and Discharge Plan: Develop an education and discharge plan to prepare the patient for self-care and a successful transition from the healthcare facility. Include topics such as medication management, follow-up appointments, lifestyle modifications, and signs and symptoms to watch for.
  10. Collaboration and Referrals: Document any collaboration with other healthcare team members, as well as referrals made to specialists or ancillary services to ensure comprehensive and coordinated care for the patient.
  • It’s important to note that the specific components and format of an iHuman care plan may vary depending on the healthcare institution, clinical setting, and patient’s unique needs.
  • The care plan should be regularly reviewed, updated, and communicated among the healthcare team to provide optimal care and achieve desired patient outcomes.

How to Write an iHuman Care Plan

Writing an iHuman care plan involves careful consideration of the patient’s needs, assessment data, and evidence-based interventions. Here are some important tips to help you effectively write an iHuman care plan:

  1. Thoroughly assess the patient: Gather comprehensive data through patient interviews, physical assessments, review of medical records, and any relevant diagnostic test results. This will provide a solid foundation for identifying nursing diagnoses and creating appropriate goals and interventions.
  2. Use standardized nursing language: Utilize standardized nursing diagnoses, such as those from NANDA International, to accurately describe the patient’s health problems and guide the development of the care plan. This helps ensure clarity, consistency, and effective communication among healthcare professionals.
  3. Prioritize nursing diagnoses: Determine the priority of nursing diagnoses based on the patient’s condition, potential risks, and immediate needs. Focus on addressing the most critical issues first while considering the patient’s preferences and preferences.
  4. Create SMART goals: Set Specific, Measurable, Attainable, Relevant, and Time-bound (SMART) goals that are patient-centered and address the identified nursing diagnoses. SMART goals provide a clear direction for care and enable effective evaluation of outcomes.
  5. Select evidence-based interventions: Choose interventions that are supported by current evidence, guidelines, and best practices. Tailor the interventions to the patient’s individual needs, preferences, and cultural considerations. Ensure that interventions are feasible and achievable within the given healthcare setting.
  6. Document evaluation criteria: Clearly define the criteria that will be used to evaluate the effectiveness of interventions and determine goal attainment. Use measurable parameters or scales to assess progress and document the patient’s response to interventions.
  7. Consider interdisciplinary collaboration: Collaborate with other healthcare team members, such as physicians, pharmacists, physical therapists, and social workers, to ensure a holistic and coordinated approach to patient care. Document any interdisciplinary collaboration and referrals made.
  8. Include patient education: Develop an education plan that empowers the patient to actively participate in their care. Provide clear and concise instructions, written materials, and demonstrations as needed. Document the topics covered, teaching methods used, and the patient’s understanding and adherence to the education provided.
  9. Regularly review and update the care plan: Continuously reassess the patient’s condition and progress, and make necessary adjustments to the care plan. Ensure that the care plan remains current and responsive to the changing needs of the patient.
  10. Communicate and share the care plan: Share the care plan with the healthcare team members involved in the patient’s care. Ensure effective communication and collaboration to promote continuity and consistency of care.
  • Remember, an iHuman care plan is a dynamic document that evolves as the patient’s condition changes.
  • It should be regularly reviewed, updated, and modified based on ongoing assessments, evaluation outcomes, and the patient’s goals and preferences.

Nursing Writing Lab