2. IMPLEMENTATION PROCESS
Reassessing the Client
Reviewing and Revising the Existing Nursing Care Plan
Organizing Resources and Care Delivery
Equipment
Personnel
Environment
Client
4. EVALUATION
Identify evaluating criteria and standards.
Collecting data to determine whether the criteria or standards
are met.
Interpreting and summarizing findings.
Documenting findings and clinical judgement.
Terminating, continuing or revising the care plan.
5. EVALUATION & QUALITY OF CARE
Appropriateness of intervention
Clinical outcome
Client satisfaction
Cost-effectiveness
Access to care
Availability of resources
6. NURSING CARE PLAN - PURPOSES
To direct clinical care
To decrease the risk of incomplete, incorrect, inaccurate care
To develop coordination of nursing care, subspecialty consultations
and scheduling of diagnostic tests.
To enhance continuity of nursing care by listing specific nursing
actions necessary to achieve the goals from one mine another.
All nurses have the opportunity to deliver high quality consistent
care.
7. TYPES OF NURSING CARE PLAN
Student Care Plan
Institutional Care Plan
Computerized Care Plan
Standardized Care Plan
Care Plan for Community-based Settings
8. MODEL NURSING CARE PLAN
Newborn suffering from Respiratory Distress Syndrome (RDS)
Assessment
Objective Data: Low body temperature - 36 C
9. MODEL NURSING CARE PLAN Cont.
Nursing Intervention
Ineffective thermoregulation related to immature temperature
control and decreased subcutaneous fat as evidenced by
hypothermia or hyperthermia.
10. MODEL NURSING CARE PLAN Cont.
Goal
To maintain normal body temperature.
11. MODEL NURSING CARE PLAN Cont.
Planning
Vital signs should be monitored.
Warm chain should be maintained.
Nesting bed should be provided.
The baby should be put on cap, hand and leg socks in an
incubator or warmer.
12. MODEL NURSING CARE PLAN Cont.
Planning Cont.
Body temperature should be maintained between 36.5 C
and 37.5 C.
Temperature of the radiant warmer should be set in servo
mode.
Room temperature should be kept within 24 C – 28 C.
Axillary temperature should be checked.
Unnecessary exposure should be avoided.
13. MODEL NURSING CARE PLAN Cont.
Planning Cont.
Wet diaper should be changed quickly.
Humidity should be maintained in bubble CPAP.
Breast feeding and kangaroo mother care should be initiated
as soon as possible.
Baby should be strictly watched for signs of hypothermia.
14. MODEL NURSING CARE PLAN Cont.
Intervention
Vital signs were checked and recorded.
Warm chain was maintained during transfer from labor room
to SNCU.
Nesting bed was provided.
The baby was put on cap, hand and leg socks in an incubator
or warmer.
15. MODEL NURSING CARE PLAN Cont.
Intervention Cont.
Body temperature was maintained between 36.5 C and
37.5 C.
Temperature of the radiant warmer was set in servo mode.
Room temperature was maintained within 26 C.
Axillary temperature was checked.
Unnecessary exposure of the baby was avoided.
16. MODEL NURSING CARE PLAN Cont.
Intervention Cont.
Wet diaper was changed quickly.
Humidity was maintained in bubble CPAP.
Baby was strictly watched for signs of hypothermia.
17. MODEL NURSING CARE PLAN Cont.
Evaluation
On 3rd Day, Body Temperature – 37.2 C.
