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Running Head: NURSING CARE PLAN SUMMARY

Nursing Care Plan Summary


Julie Arsenault
Norquest College
NFDN 1001
Assignment 2: Using Nursing Concepts and the Nursing Process to Develop a Nursing Care Plan
Cindy Hoyme

Running Head: NURSING CARE PLAN SUMMARY

Step 1: Nursing Assessment Form


Client Name: Jane Doe

__ Medical Diagnosis: Asthma

__

Client Perception of Health Needs: To find a balance between work, life, and personal time.

__

Client Goals for Health: Decrease anxiety, improve diet.

__

Allergies
(food, medication,
environmental)

Shell Fish

Medications

Ventolin PRN

Dietary
considerations

No Shellfish
Recently has been eating a poor diet.

HEALTH ASSESSMENT DATA


Fill in data from the scenario
Client

19-year-old Female
Student
Employee
Sister/Daughter
Health

Poor diet
Anxiety
Poor sleep patterns
Intermittent Asthma
Possibly exposed to illness from prior interaction with friends
Spiritual Variable (Environment)

Developmental Variable (Environment)

Not applicable

Living away from parents and family


College Student
Living with boyfriend

Running Head: NURSING CARE PLAN SUMMARY

HEALTH ASSESSMENT DATA


Sociological Variable (Environment)
Multiple Commitments (Job, Classes,
Clinical, Relationships)
Living far from her family.
Low Income
Pressure from boyfriend to spend time.

Psychological Variable (Environment)


Stressed
Anxious
Decreased sleep due to work load
Feeling pressure to spend time with boyfriend

Determinants of health impacting clients health (Environment)


Social Support Networks
Employment/Working Conditions
Health Practices/Coping Skills
Income
Health Priorities as determined by the Nurse and Client
Decrease Anxiety
Find a work-life balance
Improve diet
Develop healthy coping mechanisms
Client Strengths as determined by the Nurse and Client
Reaching out for assistance
Social Support Network
Open communication about her stresses

Running Head: NURSING CARE PLAN SUMMARY

Step 2: Nursing Diagnosis


Write three (3) nursing diagnoses one actual, one potential, and one wellness behaviour that
include the following:
NANDA approved nursing diagnosis statement - Reference to a client strength or health need
Cause/ Contributing factors (related to)
Symptom/ Presenting evidence (as evidenced by)

Actual Nursing Diagnosis


Moderate Anxiety related to situational crises and stress as evidenced by her difficulty in
maintaining her part-time job and school obligations with her other responsibilities. She is
finding it difficult to juggle all of these responsibilities and is feeling very anxious.
Potential Nursing Diagnosis
At risk for fatigue related to occupation and stress as evidenced by her difficulty maintaining
her part-time job working three 12-hr shifts in clinical an English course one evening a
week [and] trying to complete a scholarly paper
Wellness Nursing Diagnosis
Health-seeking behaviours related to a lack of knowledge about health promotion behaviours as
evidenced by her discussing her situation with you, asking for assistance with a budget-friendly
diet from her teacher, and assistance from the school with her paper.

Running Head: NURSING CARE PLAN SUMMARY

Step 3: Nursing Care Plan


PRIORITY NURSING
D IAGNOSIS
CLIENT GOAL
Write one specific and measurable
client behavioural response.

Moderate Anxiety (Chosen for the effects it is having on the


clients ability to manage her roles and the psychological
impact it is creating.)
Patient will use effective coping mechanisms to manage
anxiety.

CLIENT-CENTRED OUTCOME
Write statements in measurable terms
that support the goal by using the
SMART criteria:

Specific
Measurable
Attainable
Realistic
Time-based

In thirteen days, client will verbally express three coping


mechanisms to help manage her anxiety.

1) Discuss

IDENTIFY 3 N URSING
INTERVENTIONS
Select nursing interventions to meet
the goals set, and to change or
maintain health status

with
the client her
past use of
coping
mechanisms that
the patient has
found useful in
the past and
encourage
reintegration of
those
mechanisms.
(Gulanick &
Myers, 2011)

2) Provide

the

3) Provide the

client
client with
with a brochure
information on a
teaching the benefits of
local class held on exercise as a coping
meditation and
mechanism for anxiety.
other relaxation
Talk about different
techniques.
types of exercise and
ones which might be
realistic and desired for
the client.

Running Head: NURSING CARE PLAN SUMMARY

RATIONALE FOR
INTERVENTIONS
Provide rationale for selection of
nursing interventions and use
appropriate literature such as text,
articles, and internet sites to support
internet sites to support choices

EVALUATION
Describe how you plan to evaluate if
the goal was met or not met.

Summary
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Using anxietyreduction
strategies which
have proven
beneficial to the
client in the past
enhances the
patients sense
of personal
mastery and
confidence.
(Gulanick &
Myers, 2011)

Ask the client if


they can tell you
three ways
which they have
found helpful in
coping with
their anxiety in
stressful
situations.

Practices like
meditation,
mindfulness, and
deep breathing
exercises can help
quiet your mind
and look at
problems from a
more balanced
point of view.
With time, these
practices can help
you manage your
response to
stressful
situations.
(CMHA)

In addition to releasing
positive endorphins in
your body, exercise is a
productive way to get
some downtime away
from your job
(NursingTimes)

Running Head: NURSING CARE PLAN SUMMARY

A care plan is a tool which assists a nurse to quickly identify a clients clinical needs and
situation. A care plan includes a nursing diagnoses, goals, expected outcomes, and specific
nursing interventions. The assigned case study introduced a 19-year-old female with voiced
concerns of inability and stress due to excess responsibilities. This summary will document the
process of creating a care plan as well as the importance of using the metaparadigm concepts and
SMART criteria in planning and assessment.
Assessment
Assessment is the collection of data to determine a clients current and functional
health status (Potter & Perry, 2009). On assessment of this case study, it was important to
examine each of the metaparadigm concepts in relation to the clients story. The metaparadigm
concepts (Client, Health, Environment, and Nursing) are crucial in that all aspects are examined
to provide the most comprehensive care. This Jane Doe must not be seen as a patient but
termed a client and seen as a student, a daughter, an employee, a roommate, a person. Her
environment must be assessed with an understanding that the person is part of and interacts with
a complex environmental system (Potter & Perry, 2009) including aspects both within and
outside of herself. Health must be evaluated with the goal for a clients highest possible level of
wellness. Lastly, as a nurse you must act within your legal, ethical, and professional standards to
provide safe and effective care (Anderson, 2009).
Diagnosis
A Nursing Diagnosis is a statement which describes the clients actual or potential
response to a health problem. The diagnostic statement will provide the nurse with a direction in
which to focus care as well as information in terms of related factors and etiology. Jane Does
case study allowed for three diagnoses: Moderate Anxiety, Risk for Fatigue, and a wellness
Diagnosis of Health-Seeking Behaviours. NANDA International, Inc. provides a list of formal
nursing diagnoses; therefore, benefiting nurses with a universal nursing diagnostic language
which can be used by all professional nurses.
Planning

Running Head: NURSING CARE PLAN SUMMARY

Planning of nursing care involves creating client goals, outcomes, and selecting nursing
interventions. Planning should be completed with the client present to ensure agreement between
the client and the nurse. Each goal must follow SMART guidelines to warrant accurate
evaluation later on. In this case study, it was important that the goal (develop coping mechanisms
to manage anxiety) was specific (name three coping mechanisms), measurable (three),
achievable, realistic, and timely (by the second meeting). For Jane Doe, decreasing stress and
enhancing her coping mechanisms were the priorities on which we planned our interventions.
Implementation
Implementation is the initiation of interventions that are most likely to achieve the goals
and expected outcomes agreed upon during the planning phase. In this case study,
implementation would include client education and further counselling to teach Jane Doe
effective coping techniques and allow for an open dialogue between Jane and the nurse; therefore
continuing the therapeutic relationship formed.
Evaluation
Evaluation is the most important phase of the nursing process because you are able to
assess (with the client) whether or not the intervention has been successful. Evaluation in this
case study will include Janes own voiced perception of her progress as well as her ability to
verbalize three effective coping mechanisms which have helped in reducing her anxiety in
stressful situations.
Metaparadigm Concepts
The metaparadigm concepts are frameworks of ideas surrounding assumptions, values
and definitions which are shared within nursing. The metaparadigm concepts (Client, Health,
Environment, and Nursing) are crucial in that all aspects are examined to provide the most
comprehensive care and understanding. Jane Doe must not be seen as a patient but termed a
client and seen as a student, a daughter, an employee, a roommate, a person. Her environment
must be assessed with an understanding that the person is part of and interacts with a complex
environmental system (Potter & Perry, 2009) including aspects both within and outside of

Running Head: NURSING CARE PLAN SUMMARY

herself. Health must be evaluated with the goal for a clients highest possible level of wellness.
Lastly, as a nurse you must act within your legal, ethical, and professional standards to provide
safe and effective care.
In close, the nursing process, and that in which it entails, is of great value to all nurses.
The process itself allows for a guided, universal system in approaching any health response or
care delivery. The metaparadigm concepts help nurses to grasp the key bodies of knowledge
which are needed to understand clinical situations. Ensuring the use of SMART goals allows for
seamless follow-through and evaluation of each set outcome between the nurse and the patient.

References
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Running Head: NURSING CARE PLAN SUMMARY

Potter, P.A., & Perry, A.G. (2009) Canadian Fundamentals of Nursing (4th ed.) Toronto, ON:
Mosby Elsevier
Gulanick, M., & Myers, J. L. (2011) Nursing Care Plans, Diagnoses, Interventions, and
Outcomes (7th ed.) St. Louis, MI: Mosby Elsevier
Anderson, M. A. (2009) Nursing Leadership, Management and Professional Practice for the
LPN/LVN in Nursing School and Beyond (4th ed.) Philadelphia, PA: F. A. Davis
Company
Stress: What can I do about it? Retrieved from the Canadian Mental Health Association website:
www.cnha.ca/mentalhealth/
How to cope with stress as a student nurse. Retrieved from: www.nursingtimes.net/studentnursing-times

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