NURSING CARE PLAN GUIDE

ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES

DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient.
ASSESSMENT PLANNING EVALUATION
Universal Self Care Requisites Nursing Diagnosis Expected Outcomes Nursing Interventions Rationale Outcome Assessment

DEFINTION: DEFINITION: DEFINITION: DEFINITION: DEFINTION: DEFINTION:

(USCR) the category of self-care Problem: statement of the patient's Desired or expected outcomes of Direction for nursing action Scientific principles, theories or Responses to or results of nursing
requites that are basic and common risk for or actual health problem that nursing diagnosis: designed to assist the client and/or concepts underlying nursing interventions. An assessment of
to all humans and are constantly the nurse is licensed and accountable significant other to meet the interventions: relative data is made. These
present; these needs must be met to to treat. "Patient will" __________________ expected outcomes. Nursing actions outcome assessments describe how
achieve optimal health and well- _____________________________ are specific, realistic, and Document the source with author, the patient looks, feels or behaves
being. There are eight universal Etiology: factors "related to" or _____________________________ individualized for a particular title, edition, and page. after nursing action has been
self-care requisites: "associated with" the patient's patient. implemented.
problem. or
(1) AIR Components of nursing actions: May include proposed modifications
(2) FOOD Symptoms: manifestation of 1. Precision action verb or present plan for improvement of
(3) WATER problem identified. to____________________________ 2. Content area nursing care.
(4) ELIMINATION _____________________________ a. What-the actual measure
(5) ACTIVITY AND REST _____________________________ performed
(6) SOLITUDE AND b. Where - specific area
SOCIAL INTERACTION c. How- the means by which
(7) PREVENTION OF measures will be adopted
HAZARDS d. When - time element, how
(8) NORMALCY long or how often the
nursing action is to occur
Self-Care Agency (SCA) - assets or 3. Categories of Interventions
abilities of an individual to perform A - assessment
self-care. C - care & comfort measures
T - teaching
Self-Care Deficit (SCD) - deficit
relationship that exists when the Independent, dependent,
demand for self-care exceeds the collaborative, and supportive -
person's ability to perform self-care. educative nursing actions are to be
considered when writing the plan
Nursing System: the series of
organized concrete action performed
by nurses in collaboration with the
patient. There are three types of
nursing systems:
(1) wholly compensatory
(2) partly compensatory
(3) supportive-educative
 NURSING DIAGNOSIS: NANDA 2003

AIR SOLITUDE - SOCIAL ISOLATION

RESPIRATION EGO INTEGRITY
Airway clearance, ineffective Adjustment, impaired
Aspiration, risk for Anxiety, death
Breathing pattern, ineffective Anxiety (specify level)
Gas exchange, impaired Body image disturbed
Spontaneous ventilation: inability to sustain Conflict, decisional (specify)
Ventilatory weaning response, dysfunctional Conflict, parental role
Ventilation, impaired spontaneous Coping, ineffective community
Coping, community, readiness for enhanced
WATER Coping, compromised family
CIRCULATION Coping, disabled family
Adaptive capacity intra-cranial, decreased Coping, family, readiness for enhanced
Cardiac output, decreased Coping, defensive
Dysreflexia Coping, readiness for enhanced
Tissue perfusion, ineffective (specify): cerebral, Denial, ineffective
cardio-pulmonary, renal, gastro-intestinal Energy field, disturbed
Fear
peripheral)
Grieving, anticipatory
Grieving, dysfunctional
FLUID Hopelessness
Fluid volume deficit Personal identity disturbed
Fluid volume deficit, risk for Post trauma response
Fluid volume excess Powerlessness
Fluid volume imbalance, risk for Powerlessness, risk for
Fluid volume, readiness for enhanced Rape-trauma syndrome
Oral mucous membranes, impaired Rape-trauma syndrome: compound reaction
Swallowing, impaired Rape-trauma syndrome: silent reaction
Relocation stress syndrome
Relocation stress syndrome, risk for
FOOD Self-concept, readiness for enhanced
FOOD/FLUID Self-esteem, chronic low
Breastfeeding, effective Self-esteem, situational low
Breastfeeding, ineffective Self-esteem, situational low, risk for
Breastfeeding, interrupted Sorrow, chronic
Dentition, impaired Spiritual distress
Infant feeding pattern, ineffective Spiritual distress, risk for
Nausea
Nutrition, imbalanced: less than body requirements SOCIAL INTERACTION
Nutrition, imbalanced: more than body Caregiver role strain
requirements Caregiver role strain, risk for
Nutrition, readiness for enhanced Communication impaired, verbal
Nutrition, imbalanced: risk for more than body Communication, readiness for enhanced
requirements Community coping, enhanced, potential for
Community coping, ineffective
Environmental interpretation syndrome, Impaired
Failure to thrive, adult
ELIMINATION Family coping, ineffective: compromised
ELIMINATION Family coping, ineffective: disabling
Constipation Family coping, potential for growth
Constipation, risk for Family process, dysfunctional: alcoholism
Constipation, perceived Family processes, interrupted
Diarrhea Family processes, readiness for enhanced
Incontinence, bowel Loneliness, risk for
Incontinence, functional (urinary) Parent/infant/child attachment impaired, risk for
Incontinence, reflex (urinary) Parenting, impaired
Incontinence, stress (urinary) Parenting, impaired risk for
Incontinence, total (urinary) Parenting, readiness for enhanced
Incontinence, urge (urinary) Role performance, ineffective
Incontinence, urge (urinary) risk for Role strain, caregiver
Urinary elimination, impaired Role strain, caregiver, risk for
Urinary elimination, readiness for enhanced Social interaction, impaired
Urinary retention Social isolation

NEUROSENSORY
ACTIVITY/REST Confusion, acute
ACTIVITY/REST Confusion, chronic
Activity intolerance Infant behavior, disorganized
Activity intolerance, risk for Infant behavior, disorganized, risk for
Disuse syndrome, risk for Infant behavior, organized, potential for
Diversional activity deficient enhancement
Fatigue Memory, impaired
Sleep deprivation Peripheral neurovascular dysfunction, risk for
Sleep, readiness for enhanced Sensory-perceptual alterations (specify): visual,
Sleep pattern disturbed auditory, kinesthetic, gustatory, tactile,
Transfer ability, impaired olfactory
Walking, impaired
SEXUALITY (COMPONENT OF EGO
HYGIENE INTEGRITY AND SOCIAL INTERACTION)
Self-care deficit (specify): feeding, bathing/ Sexual dysfunction
hygiene, dressing/grooming, toileting Sexuality patterns, ineffective

PAIN/COMFORT
Pain, (acute)
Pain, chronic NORMALCY
Injury, risk for EGO INTEGRITY
Perioperative positioning injury, risk for Fear
Physical mobility, impaired Grieving, anticipatory
Social isolation Grieving, dysfunctional
Hopelessness
Personal identity disturbed
HAZARDS Post-trauma syndrome
SAFETY Post-trauma syndrome, risk for
Body temperature, imbalanced, risk for Spiritual well-being, readiness for enhancement
Environment interpretation syndrome, impaired
Falls, risk for TEACHING/LEARNING
Health maintenance, ineffective Development, risk for delayed
Home maintenance, impaired Growth and development, delayed
Hyperthermia Growth, Risk for disproportionate
Hypothermia/infection, risk for Health-seeking behaviors (specify)
Infection: Risk for or actual Knowledge deficient (specify)
Injury, risk for Knowledge (specify), readiness for enhanced
Latex allergy, response Management of therapeutic regime, effective
Latex allergy response, risk for Management of therapeutic regime, Ineffective
Mobility impaired, physical Management of therapeutic regime, readiness for
Mobility impaired, bed enhanced
Mobility impaired, wheelchair Management of therapeutic regimen: Community,
Perioperative positioning injury, risk for ineffective
Physical mobility, impaired Management of therapeutic regimen: family
Poisoning, risk for ineffective
Protection, ineffective Non-compliance (compliance, altered) (specify)
Self-mutilation
Self-mutilation, risk for
Skin integrity, impaired
Skin integrity, impaired, risk for
Sudden infant death syndrome, risk for NANDA 2004
Suffocation, risk for
Thermoregulation ineffective
Tissue integrity, impaired
Trauma, risk for
Violence, other directed, risk for
Violence, self directed, risk for
Wandering

NEUROSENSORY
Confusion, acute
Confusion, chronic
Infant behavior, disorganized
Infant behavior, disorganized, risk for
Infant behavior, organized, readiness for
enhanced
Memory, impaired
Neglect, unilateral
Peripheral neurovascular dysfunction, risk for
Sensory-perceptual disturbed (specify): visual,
auditory, kinesthetic, gustatory, tactile,
olfactory