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Nursing Care Plan
Prepared By :
Meraljane Paras
Preferred College of Nursing
NURSING PROCESS =
SCIENTIFIC METHOD + CRITICAL THINKING
STEPS IN NURSING PROCESS
Assessment Nursing Diagnosis Planning Intervention Evaluation
ASSESSMENT
Systematic and continuous collection of data
NURSING DIAGNOSIS
The statement of the clients actual or potential problem
PLANNING
The development of goals for care and possible activities to meet them
INTERVENTION
The giving of the actual nursing care
EVALUATION
The measurement of the effectiveness of nursing care
Activity 1
Identify what step in the nursing process are the following?
Pain related to myocardial ischemia as manifested by guarding left chest, grimacing, moaning pain score of 10/10, Bp 170/80 HR 123
-nursing diagnosis
At the end of the shift the patient will be able to ambulate at the end of the hallway.
planning/expected outcome
Pulse rate of 150 and irregular assessment
Ambulate patient TID intervention
Decreased use of accessory muscles; client reporting a decreased in shortness of breath and decrease in difficulty breathing? Goal met
evaluation
NURSING CARE PLAN
Formal guideline for directing nursing staff to provide client care
purpose of a nursing care plan is to identify problems of a patient and find solutions to the problems
NURSING CARE PLAN
Patient’s Initials____ Diagnosis ___________
Problem list Nursing Diagnosis
Goals
Short term
Long term
Implementation/ rationale
Evaluation
NURSING CARE PLAN
Patient’s Initials____ Diagnosis ___________
Problem list
Assessment
Subjective=based on what the patient says
Objective= based on your observation, laboratory data, and vitals signs
Nursing Diagnosis
5 kinds of nursing diagnosis• Actual• Risk Potential nursing diagnoses• Possible nursing diagnoses• Wellness diagnoses• Syndrome diagnoses
• Actual Diagnoses the persons data base contains evidence of signs and symptoms or defining characteristics of the diagnoses
• 3 part statement• PES (Problem + etiology + signs and symptoms)
Nursing Diagnosis
•Problem: Nanda (North American nursing diagnosis association) Approve Nursing diagnosis
•Etiology: written as related to= is often part of the medical diagnosis
•Signs and Symptoms written as: “as evidenced by" (AEB)
= should include your assessment data of how you decided on that particular diagnosis
NURSING CARE PLANPatient’s Initials____ Diagnosis ___________
Nursing diagnosis/ related to/ as manifested by
Ineffective airway clearance/ related to physiologic effects of pneumonia/ as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea
Example of actual nursing diagnosis
Risk diagnosis
The persons data base contains evidence of related (risk factors of the diagnosis, but no evidence of the defining characteristics
Problem + etiology Risk for impaired skin integrity/ related to obesity,
excessive diaphoresis and confinement to bed No signs and symptoms
Possible diagnosis
The person’s data base doesn’t demonstrate the defining characteristics or related factors of the diagnosis, but your intuition tells you the diagnosis may be present
One part statement and simply name the possible problem
Ex. Possible ineffective individual coping
Wellness diagnoses
Being able to diagnose wellness diagnoses is based on recognizing when healthy clients indicate a desire to achieve a higher level of functioning in a specific area
One part statement use the word potential for enhanced
Pt says I wish I were a better parent
Nursing diagnosis: Potential for enhanced parenting
Syndrome diagnosis
There are only two syndrome diagnosis on the NANDA list
Disuse syndrome Rape and trauma syndrome
You use a syndrome diagnosis when the diagnosis is associated with a cluster of other diagnosis (often seen in bedridden nursing home care residents)
It is a one part statement. Simply name the syndrome
Nursing Diagnoses associated with disuse syndrome
Impaired physical mobility Risk for constipation Risk for altered respiratory function risk for infection Risk for activity intolerance Risk for injury Risk for altered thought process Risk for body image disturbance Risk for powerlessness Risk for impaired tissue integrity
Activity 2
Identify what kind of nursing diagnosis
Impaired communication/ related to language barrier/ as evidenced by inability to speak or understand English and use of Spanish
actual nursing diagnosis
Possible altered sexuality pattern Possible nursing diagnosis
Rape trauma syndrome
Syndrome diagnosis
Potential for enhanced care giver Wellness diagnoses
Risk for aspiration related to impaired swallowing
Risk nursing diagnoses
Activity #3
Identify if the statement is correct. If not correct the statement
risk for injury related to lack of the side rails on bed
Xdo not write statement in such a way that it may
be legally incriminating√: risk for injury related to disorientation
Rape trauma syndrome
√
One part statement only
Mastectomy related to cancer
X do not state the nursing diagnosis using
medical terminology. Focus on the persons response to medical problems
√:Risk for self concept disturbance related to effects of the mastectomy
Pain and fear related to diagnostic procedure
X do not state two problem at the same time
√:fear related unfamiliarity with diagnostic procedures
pain related to diagnostic procedure
Risk for confinement related to confinement to bed
√
One part statement only
Spiritual distress related to atheism as evidenced by statements that she has never believe in GOD
X don’t write a nursing diagnosis based on value
judgment
√:there may be no diagnosis in this situation. The person may be at peace with her beliefs not with yours
Components of expected Outcome• Subject: Who is the person expected to achieve the
outcome?• Verb: What actions must the person take to achieve the
outcome?• Condition; Under what circumstances is the person to
perform the actions?• Performance criteria: How well is the person to perform
the actions:• Target time: By when is the person expected to be able
to perform the actions?
Planning/ expected outcome
Mr. Smith will walk with a cane at least to the end of the
hall and back by Friday
• Subject: Mr. Smith • Verb: will walk • Condition; with a cane • Performance criteria at least to the end of the
hall and back • Target time: by Friday
Planning/ expected outcome
Measurable verbs• Identify• Describe• Perform• Relate• State• List• Verbalize• Hold• Demonstrate
•Share
•Express
•Will loose
•Will gain
•Has an absence of
•Exercise
•Communicate
•Cough
•Walk
•Stand sit
Non measurable verbs (Do not use)
Know Understand Appreciate Think Accept feel
Identify if the statement are written correctly
John will know the four basic food groups by 6/30/07
X The verb is not measurable
√ John will list the four basic food groups by 6/30/07
Identify if the statement are written correctly
Mrs. S will demonstrate how to use her walker unassisted by saturday
√ • Subject: Mrs. S • Verb: will demonstrate• Condition; will use her walker• Performance criteria unassisted• Target time: by Saturday
Identify if the statement are written correctly
After 1 hour Mrs. G will verbalize decrease level of pain from 10/10 to 3/10.
√ • Subject: Mrs G• Verb: will verbalize• Condition; decrease level of pain• Performance criteria from 10/10 to 3/10• Target time: after 1 hour
NURSING CARE PLAN
Patient’s Initials____ Diagnosis ___________
Intervention/ rationale
•Should be based on your scope of practice•Make sure you know the rationale of your intervention•Include health teaching
NURSING CARE PLAN
Patient’s Initials____ Diagnosis ___________
Evaluation
Either goal met , partially met or , not met
NURSING CARE PLAN
Patient’s Initials_J.R.__ Diagnosis ___________
Problem list Nursing Diagnosis
Goals
Short term
Long term
Implementation/ rationale
Evaluation
Activity # 4 write a care plan for the following problem.
1. Pt who has diarrhea
2. Pt who is constipated
3. Pt who has a fever
4. Pt who has stage II decubitus ulcer
5. Pt who is in pain or create a care plan using
1. Ineffective airway clearance
2. Risk for aspiration
3. Risk for infection
4. Impaired physical mobility
Activity #5 PRACTISE QUESTIONS
1.) A Nurse is assigned to care for a patient receiving enteral feedings. The nurse plans care knowing that which of the following is a highest priority for the client
a.) altered nutritionb.) risk for aspiration
c.) risk for fluid volume deficit d.) risk for diarrhea
Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration.
Options 1 and 4 maybe appropriate nursing diagnoses but are not of highest priority.
Option 3 is not likely to occur
The nurse is teaching a client with diabetes mellitus about dietary measures to follow. The client express frustration in learning the dietary regimen. The nurse would initially
1. Identify the cause of the frustration
2. Continue with the dietary teaching
3. Notify the physician
4. Tell the client that the diet needs to be followed
Use the steps of the nursing process. Assessment is the first step. Of the four options presented, the only assessment is option option1. option 2,3 and 4 are implementation. The initial action is to identify the cause of the frustration
Pain related to surgical incision as manifested by moaning, guarding incision site, pain 10/10
which part is etiology?
which part is the problem?
which part is the signs and symptoms?
Activity#6
What are the possible nursing diagnoses for someone who has the following condition?
Pt who has a trache? Pt who has a stroke Post op patient
