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

 Thestatement of the clients actual or

potential problem
PLANNING

 Thedevelopment of goals for care and

possible activities to meet them
INTERVENTION

 The giving of the actual nursing care

EVALUATION

 Themeasurement 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
 Pulserate 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 Goals Implementation/ Evaluation

Diagnosis Short term rationale
Long term
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

 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
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 •Share
• Describe •Express
• Perform
•Will loose
• Relate
• State •Will gain
• List •Has an absence of
• Verbalize •Exercise
• Hold
•Communicate
• Demonstrate
•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 Goals Implementation/ Evaluation

Diagnosis Short term rationale
Long term
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
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