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

2. NURSING PROCESS =
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 PLAN Patient’s Initials____ Diagnosis ___________
Problem list
Nursing Diagnosis
Goals
Short term
Long term
Implementation/ rationale
Evaluation

16. 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

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. Signs and Symptoms written as: “as evidenced by" (AEB)
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
Signs and Symptoms written as: “as evidenced by" (AEB)
= should include your assessment data of how you decided on that particular 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 cancerX
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 procedureX
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 GODX
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 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

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 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

45. NURSING CARE PLAN Patient’s Initials____ Diagnosis ___________
Evaluation
Either goal met , partially met or , not met

46. NURSING CARE PLAN Patient’s Initials_J.R.__ Diagnosis ___________
Problem list
Nursing Diagnosis
Goals
Short term
Long term
Implementation/ rationale
Evaluation

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

51. Use the steps of the nursing process. Assessment is the first step
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

52. 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?

53. 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