Individualized
Care Plans
Fully Developed
1
Refer to Chapter 1 “The Nursing Process: A Synopsis,” p. 32: Two Individualized
Care Plans Fully Developed; Care Plan 1 for Mr. John Walters, Care Plan 2 for
Mrs. Mary Smith.
All nursing actions and behaviors (nursing interventions) should focus on
the individual client’s assessment.
How can you be certain that the assessment in the completed care plan for
Mr. John Walters focused on the physical examination, interview, and data
col-lected from the client’s chart?
Activity 1
Examine the ordered and selected data for Mr. Walters (first column of
Individualized Care Plan 1).
a. Physical examination (objective data) nonverbal behavior, attentive
(body posture) demonstrates genuine concern for knowledge (readiness
to learn).
b. Interview (subjective data) client states, “I have no idea what to do about
this condition.”
c. Data collected from the client’s chart: medical
diagnosis—Hemor-rhoidectomy (first postoperative day).
A
How can you be certain that the nursing diagnosis is formulated from what
the client says (the subjective data) and what is found during the physical
assessment (objective data) and that the nursing diagnosis is named from the
NANDA list as it applies to Mr. Walters?
Activity 2
Look again at the ordered/selected column and notice that the client is saying
that he does not know how to care for his condition and that his nonverbal
communication (objective data) confirms his desire for knowledge. Now
exam-ine the NANDA list of nursing diagnoses (p. 169) and observe that the
diag-nosis that relates to lack of knowledge is Knowledge, Deficient.
Be sure to relate this diagnosis to the specific information that your client
is seeking (read the diagnosis as written in Individualized Care Plan 1).
How do you know when your defining characteristics are correct?
Remember that the defining characteristics should substantiate your nursing
diagnosis and at least three should match your objective subjective data.
Activity 3
Examine the defining characteristics in the completed Individualized Care Plan
1. Notice that three characteristics correspond with the objective/subjective
data: voiced lack of knowledge, demonstrated readiness to learn, and asked
questions.
How do you know that the goals relate specifically to Mr. Walters and that
they are attainable?
Activity 4
Examine the goals column in the care plan for Mr. Walters. Notice that the
short-term goal has the client answering the very questions he asked and the
long-term goal has him doing what he needs to do in order to care for himself.
How do you know that the interventions involve both client and nurse?
Activity 5
Examine the nursing interventions for Mr. Walters. Notice that they are quite
comprehensive: details are explained to him, the nurse demonstrates the
pro-cedures, and he is given the opportunity to perform these tasks.
Activity 6
Examine the rationale column of the completed care plan for Mr. Walters.
Notice that there is a rationale (a reason) for each intervention but that these
can be used for any client with similar nursing interventions.
Were the stated goals realized for Mr. Walters?
Activity 7
Examine the evaluation column of the completed care plan for Mr. Walters.
Note that the client now understands what to do (both short term and long
term). The long-term results show him performing the procedures he was
taught by the second day and repeating what to do while in the hospital and
at home (goal met).
Activity 8
Examine Care Plan 2 the same way you did for Care Plan 1 and you will
real-ize that Care Plan 2 is sequential and individualreal-ized to the 84-year-old client
with a nursing diagnosis of Risk for Impaired Skin Integrity.
Subjective data: Knowledge deficit Short term: Teach the client the Short term Client states about self-care after Client will verbalize following goal met: Client “I have no idea what hemorrhoidectomy understanding of the interacted in the to do about this evidenced by client’s things he needs to do teaching session, condition; what statement and on the first operation stated, “I will do do I do?” nonverbal behavior day between 0800 those things.”
(see ordered & and 1000.
Objective data: selected data. Long term goal met:
Nonverbal behavior Long term: Self care on second
demonstrates genuine Defining Client will demonstrate day with little concern for knowing— characteristics: techniques that need assistance. attentive, expectant • Voices lack of to be performed in the
(readiness to learn). knowledge hospital and at home Rehearsed the things
• Demonstrates on the second to report while in the readiness to learn postoperative day. hospital and after
(attentive, going home.
expectant) • Reluctant to touch affected area. • Asks questions about the condition.
4
CLIENT: Mr. John Walters Individualized Care Plan 1 for Appendix A Knowledge Deficit
AGE: 50 MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)
Ordered &
Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation
• This procedure will cause much pain.
• Medication is available every 3 hours and should be taken on days 1 and 2 after surgery.
• Sitz baths are necessary and should begin the first day after surgery.
• A rubber ring will be placed in the bathtub and he will sit on it. The nurse will be in attendance.
• Understanding of underlying principles of care fosters cooperation and decreases anxiety. The rectum is very vascular, bleeds easily, and causes much pain.
• Client comfort is a priority with the nurse. Suffering is contradictory to good nursing care.
• Enhances comfort and aids healing. Water is a cleaning agent that also prevents accumulation of bacteria.
• Provides a soft cushion. Client should not be left alone because of the potential for fainting after general anesthesia, NPO state, decreased food and fluid intake, and
5
CLIENT: Mr. John Walters Individualized Care Plan 1 for Appendix A Knowledge Deficit (continued)
AGE: 50 MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)
Ordered &
Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation
• A packing is in his rectum, which will be removed the second morning.
• He is to continue to wear the T-binder and will be provided with a clean one as needed.
• He should ask for pain medication before he has a bowel movement.
• His oral medication will keep his stool soft. An oil retention enema (to soften stool) may be given on day 3 if he does not have a bowel movement. He should eat higher fiber foods.
• The area should be thoroughly washed after every bowel movement.
• Aids in the absorption of drainage (bloody or serosanguinous).
• Keeps dressing in place and avoids contamination of wound.
• Decreases actual pain and anxiety related to first bowel movement.
• Colace to be given routinely as a stool softener. Oil retention enema concentrates in lower bowel and rectum and facilitates passage of soft stool.
• Bleeding, infection, and pain are still possible complications while in the hospital and after discharge.
Subjective data: Client Risk for impaired skin Short term: Discuss the plan of Understanding of the Short-term goal met: Client states “I am skin and integrity. Client’s skin will care and the rationale medical and nursing stated, “I know how bones.” show no signs of for each action with regimen will enhance it is to get a bedsore.
Defining impairment between the client client’s cooperation. I have had them before; Objective data: characteristics: 0700 and 1500, on (solicit cooperation). I surely do not want Skin dry and intact, Risk factors 09/06/03. any more.” warm to touch • Immobility • Turn every two hours • Sheering forces
• Moisture Long term: • Remove sheering against the skin No evidence of redness Height: 5 feet, (diaphoresis) Client’s skin will forces at least every will cause irritation or irritation on day 1. 3 inches • Variations in remain intact on 4 hours (tighten draw and alter the integrity
temperature 09/07/03. sheet, remove debris). on the first defense
Weight: 95 pounds (very hot or • Gently insert bedpan. (skin). Long-term goal met: No
Ideal body weight: very cold) alteration in skin
127 pounds • Malnourished • Change linen if • Moisture encourages integrity. Staff asked Evidence of muscle • Age (elder) accidents (wet spots) bacterial growth, to continue the wasting. • Impaired circulation occur. causing damage and regimen begun by the
• Poor skin turgor infection to tissue. student nurse.
• Trauma (sheering forces: bed sheets, bedpan)
• Neurological deficits
(impaired sensation) continues
6
CLIENT: Mrs. Mary Smith Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity
AGE: 84 MEDICAL DIAGNOSIS: Severe weight loss
Ordered &
7
• Daily bath and • Daily hygienic thorough cleansing measures eliminate after urination and odors and prevent defecation. infections.
• Ambulation at least • Activity (exercise) twice daily. improves the
functioning of all organ systems.
• Increase fluid intake • Proper nutrition daily (start with 2 strengthens the glasses and increase immune system and to 8 daily) helps to maintain a
• Select foods that have healthy state. Fluids high vitamin, high bathe body tissue, protein, and high remove waste and carbohydrate content. aid in fluid balance.
• Endeavor to eat as much as possible (include midmorning and evening snacks).
CLIENT: Mrs. Mary Smith Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity (continued)
AGE: 84 MEDICAL DIAGNOSIS: Severe weight loss
Ordered &
Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation
