Nursing Care Plan

Nursing Care

Plan

Prepared By :

Meraljane Paras

NURSING PROCESS =

STEPS IN NURSING PROCESS

ASSESSMENT

NURSING DIAGNOSIS

 The statement of the clients actual or

PLANNING

 The development of goals for care and

INTERVENTION

EVALUATION

 The measurement of the effectiveness of

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

 At the end of the shift the patient will be able

to ambulate at the end of the hallway.

 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

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

____

___________

Evaluation Implementation/ rationale Goals Short term Long term Nursing Diagnosis Problem list

NURSING CARE PLAN

Patient’s Initials

____

___________

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)

•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 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

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

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

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

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

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

 Possible altered sexuality pattern  Possible nursing diagnosis

 Rape trauma syndrome

 Potential for enhanced care giver  Wellness diagnoses

 Risk for aspiration related to impaired

swallowing

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

 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

 Risk for confinement related to confinement

to bed

√

 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

 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?

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

Measurable verbs

Non measurable verbs (Do not use)

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



√

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}

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

____

___________

•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

____

___________

Either goal met , partially met or , not met

NURSING CARE PLAN

Patient’s Initials_J.M__

___________

Evaluation Implementation/ rationale Goals Short term Long term Nursing Diagnosis Problem list

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. Ineffective airway clearance 8. Risk for aspiration

9. Risk for infection

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

 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

 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?

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