Transcript Nursing Care Plan

Preferred College of Nursing
Nursing Care
Plan
Prepared By :
Meraljane Paras
NURSING PROCESS =
SCIENTIFIC METHOD + CRITICAL THINKING
STEPS IN NURSING PROCESS
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Assessment
Nursing Diagnosis
Planning
Intervention
Evaluation
ASSESSMENT
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Systematic and continuous collection of data
NURSING DIAGNOSIS
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The statement of the clients actual or
potential problem
PLANNING
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The development of goals for care and
possible activities to meet them
INTERVENTION
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The giving of the actual nursing care
EVALUATION
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The measurement of the effectiveness of
nursing care
Activity 1
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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
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-nursing diagnosis
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At the end of the shift the patient will be able
to ambulate at the end of the hallway.
planning/expected outcome
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Pulse rate of 150 and irregular
assessment
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Ambulate patient TID
intervention
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Decreased use of accessory muscles; client
reporting a decreased in shortness of breath
and decrease in difficulty breathing? Goal
met
evaluation
NURSING CARE PLAN
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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____
Problem list
Nursing
Diagnosis
Diagnosis
Goals
Short term
Long term
___________
Implementation/ Evaluation
rationale
NURSING CARE PLAN
Patient’s Initials____
Problem list
Assessment
Subjective=based on what the
patient says
Objective= based on your
observation, laboratory data,
and vitals signs
Diagnosis
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Nursing Diagnosis
5 kinds of nursing diagnosis
• Actual
• Risk Potential nursing diagnoses
• Possible nursing diagnoses
• Wellness diagnoses
• Syndrome diagnoses
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Actual Diagnoses the persons data base contains
evidence of signs and symptoms or defining
characteristics of the diagnoses
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3 part statement
PES (Problem + etiology + signs and symptoms)
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NURSING CARE PLAN
Patient’s Initials____
Diagnosis ___________
Nursing Diagnosis
•Problem:
Nanda (North American nursing diagnosis association)
Approve Nursing diagnosis
•Etiology:
written as related to= is often part of the medical
diagnosis
and Symptoms written as: “as evidenced by" (AEB)
= should include your assessment data of how you decided on
that particular diagnosis
•Signs
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
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The persons data base contains evidence of related
(risk factors of the diagnosis, but no evidence of the
defining characteristics
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Problem + etiology
Risk for impaired skin integrity/ related to obesity,
excessive diaphoresis and confinement to bed
No signs and symptoms
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Possible diagnosis
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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
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Ex. Possible ineffective individual coping
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
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Syndrome diagnosis
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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
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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
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Possible altered sexuality pattern
Possible nursing diagnosis
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Rape trauma syndrome
Syndrome diagnosis
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Potential for enhanced care giver
Wellness diagnoses
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Risk for aspiration related to impaired
swallowing
Risk nursing diagnoses
Activity #3
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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
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Rape trauma syndrome
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One part statement only
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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
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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
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One part statement only
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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
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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
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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
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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)
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Know
Understand
Appreciate
Think
Accept
feel
Identify if the statement are written
correctly
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John will know the four basic food groups by
6/30/07
X
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The verb is not measurable
 √ John will list the four basic food groups by
6/30/07
Identify if the statement are written
correctly
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Mrs. S will demonstrate how to use her walker
unassisted by saturday
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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
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After 1 hour Mrs. G will verbalize decrease level of
pain from 10/10 to 3/10.
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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____
Evaluation
Either goal met , partially met or
, not met
Diagnosis
___________
NURSING CARE PLAN
Patient’s Initials_J.R.__
Problem list
Nursing
Diagnosis
Diagnosis
Goals
Short term
Long term
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Implementation/ Evaluation
rationale
Activity # 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
1.
Ineffective airway clearance
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Risk for aspiration
3.
Risk for infection
4.
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
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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
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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
implementation. 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
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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