Nursing Care Plan

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Nursing Care Plan
Preferred College of Nursing

• Prepared By
• Meraljane Paras

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NURSING PROCESS
SCIENTIFIC METHOD CRITICAL THINKING
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STEPS IN NURSING PROCESS

• Assessment
• Nursing Diagnosis
• Planning
• Intervention
• Evaluation

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ASSESSMENT

• Systematic and continuous collection of data

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NURSING DIAGNOSIS

• The statement of the clients actual or potential
  problem

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PLANNING

• The development of goals for care and possible
  activities to meet them

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INTERVENTION

• The giving of the actual nursing care

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EVALUATION

• The measurement of the effectiveness of nursing
  care

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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

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• At the end of the shift the patient will be able
  to ambulate at the end of the hallway.
• planning/expected outcome

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• Pulse rate of 150 and irregular
• assessment

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• Ambulate patient TID
• intervention

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• Decreased use of accessory muscles client
  reporting a decreased in shortness of breath and
  decrease in difficulty breathing? Goal met
• evaluation

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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

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NURSING CARE PLANPatients Initials____
Diagnosis ___________
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NURSING CARE PLANPatients Initials____
Diagnosis ___________
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• Nursing Diagnosis
• 5 kinds of nursing diagnosis
• Actual
• Risk Potential nursing diagnoses
• Possible nursing diagnoses
• Wellness diagnoses
• Syndrome diagnoses

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• 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)

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(No Transcript)
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Example of actual nursing 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
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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

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Possible diagnosis

• The persons data base doesnt 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

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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

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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

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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

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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

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• Possible altered sexuality pattern
• Possible nursing diagnosis

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• Rape trauma syndrome
• Syndrome diagnosis

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• Potential for enhanced care giver
• Wellness diagnoses

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• Risk for aspiration related to impaired
  swallowing
• Risk nursing diagnoses

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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
• X
• do not write statement in such a way that it may
  be legally incriminating
• v risk for injury related to disorientation

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• Rape trauma syndrome
• v
• One part statement only

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• Mastectomy related to cancer
• X
• do not state the nursing diagnosis using
  medical terminology. Focus on the persons
  response to medical problems
• vRisk for self concept disturbance related to
  effects of the mastectomy

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• Pain and fear related to diagnostic procedure
• X
• do not state two problem at the same time
• vfear related unfamiliarity with diagnostic
  procedures
• pain related to diagnostic procedure

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• Risk for confinement related to confinement to
  bed
• v
• One part statement only

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• Spiritual distress related to atheism as
  evidenced by statements that she has never
  believe in GOD
• X
• dont write a nursing diagnosis based on
  value judgment
• vthere may be no diagnosis in this situation.
  The person may be at peace with her beliefs not
  with yours

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Planning/ expected outcome

• 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?

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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

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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

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Non measurable verbs (Do not use)

• Know
• Understand
• Appreciate
• Think
• Accept
• feel

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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
• v John will list the four basic food groups by
  6/30/07

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Identify if the statement are written correctly

• Mrs. S will demonstrate how to use her walker
  unassisted by saturday
• v
• Subject Mrs. S
• Verb will demonstrate
• Condition will use her walker
• Performance criteria unassisted
• Target time by Saturday

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Identify if the statement are written correctly

• After 1 hour Mrs. G will verbalize decrease level
  of pain from 10/10 to 3/10.
• v
• Subject Mrs G
• Verb will verbalize
• Condition decrease level of pain
• Performance criteria from 10/10 to 3/10
• Target time after 1 hour

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NURSING CARE PLANPatients Initials____
Diagnosis ___________
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NURSING CARE PLANPatients Initials____
Diagnosis ___________
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NURSING CARE PLANPatients Initials_J.M__
Diagnosis ___________
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Activty 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
• Ineffective airway clearance
• Risk for aspiration
• Risk for infection
• Impaired physical mobility

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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 nutrition
• b.) risk for aspiration
• c.) risk for fluid volume deficit
• d.) risk for diarrhea

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• 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

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• 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

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• 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 implentation. The initial action is to
  identify the cause of the frustration

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• 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?

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Activity6

• 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