Preferred College of Nursing

Nursing Care Plan

Prepared By :

Meraljane Paras

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/ Evaluation rationale

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

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

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 Possible ineffective individual coping

 Ex.

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

X
do 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

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?

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

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.M__ Diagnosis

___________

Problem list

Nursing Diagnosis

Goals Short term Long term

Implementation/ Evaluation rationale

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 7. 8. 9. Ineffective airway clearance Risk for aspiration Risk for infection

10. 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 nutrition b.) 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 implentation. 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

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