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Nursing Care Plan

Nursing Care Plan. Preferred College of Nursing. 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.

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Nursing Care Plan

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  1. Nursing Care Plan Preferred College of Nursing Prepared By : Meraljane Paras

  2. NURSINGPROCESS = SCIENTIFIC METHOD + CRITICAL THINKING

  3. STEPS IN NURSING PROCESS • Assessment • Nursing Diagnosis • Planning • Intervention • Evaluation

  4. ASSESSMENT • Systematic and continuous collection of data

  5. NURSING DIAGNOSIS • The statement of the clients actual or potential problem

  6. PLANNING • The development of goals for care and possible activities to meet them

  7. INTERVENTION • The giving of the actual nursing care

  8. EVALUATION • The measurement of the effectiveness of nursing care

  9. 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

  10. At the end of the shift the patient will be able to ambulate at the end of the hallway. • planning/expected outcome

  11. Pulse rate of 150 and irregular • assessment

  12. Ambulate patient TID • intervention

  13. Decreased use of accessory muscles; client reporting a decreased in shortness of breath and decrease in difficulty breathing? Goal met • evaluation

  14. 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

  15. NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

  16. NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

  17. Nursing Diagnosis 5 kinds of nursing diagnosis • Actual • Risk Potential nursing diagnoses • Possible nursing diagnoses • Wellness diagnoses • Syndrome diagnoses

  18. 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)

  19. NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

  20. 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

  21. 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

  22. 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 • Ex. Possible ineffective individual coping

  23. 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

  24. 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

  25. 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

  26. 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

  27. Possible altered sexuality pattern • Possible nursing diagnosis

  28. Rape trauma syndrome Syndrome diagnosis

  29. Potential for enhanced care giver • Wellness diagnoses

  30. Risk for aspiration related to impaired swallowing • Risk nursing diagnoses

  31. 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

  32. Rape trauma syndrome √ One part statement only

  33. 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

  34. 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

  35. Risk for confinement related to confinement to bed √ One part statement only

  36. 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

  37. 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?

  38. 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

  39. Measurable verbs • Share • Express • Will loose • Will gain • Has an absence of • Exercise • Communicate • Cough • Walk • Stand sit • Identify • Describe • Perform • Relate • State • List • Verbalize • Hold • Demonstrate

  40. Non measurable verbs (Do not use) • Know • Understand • Appreciate • Think • Accept • feel

  41. 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

  42. 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

  43. 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

  44. NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

  45. NURSING CARE PLANPatient’s Initials____ Diagnosis ___________

  46. NURSING CARE PLANPatient’s Initials_J.R.__Diagnosis ___________

  47. 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 • Ineffective airway clearance • Risk for aspiration • Risk for infection • Impaired physical mobility

  48. 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

  49. 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

  50. 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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