Easiest way to make Nursing care plan

1. Presented by :Akshita negi
( Bsc. Nursing 2nd Sem )
Nursing process

2. Nursing process
Nursing process is the critical thinking
process that professional nurse use to
apply the best available evidence to
caregiving and promoting human functions
and responses to health
-American nurses Association ,2019

3. Steps of nursing process
Nursing process is a systematic series of 5
steps these are :
• Assessment
• Nursing diagnosis
• Outcome / planning
• Implementation
• Evaluation

4. Steps of nursing process

5. 1. Assessment
• Assessment is the first step of the nursing
process .It involves the use of critical
thinking skills for data collection :
• Subjective data
• Objective data

6. • Subjected data are information perceived
only by the affected person it includes
feelings , perceptions , and self report of
symptoms .The data sometimes reflects
physiological changes which can be
explore through objective data collection
• example: feeling nervous ,nauseated or
chilly and experiencing pain

7. • Objective data ;These are observable
and measurable data that can be seen
,heard ,felt or measured by someone
other than the person experiencing them .
• The measurement of objective data is
based on an accepted standard such as
degree F or C

8. • Example :elevated temperature reading
(e.g.,102 degree F) ,skin that is moist
,refusal to look at or eat food .It is also
called as signs or overt data

9. 2. Nursing diagnosis :
Nursing diagnosis is defined as a clinical
Judgement about individual ,family, or
community responses to actual and potential
health /life processes .Nursing diagnosis
provides the basis for selection of nursing
interventions to achieve outcomes for which the
nurse is accountable .
-North American nursing diagnosis Association ( NANDA) ,1993

10. Types of nursing diagnosis
• problem focused nursing diagnoses or
actual nursing diagnoses
• Risk nursing diagnoses or potential
nursing diagnoses
• Health promotion nursing diagnoses or
wellness nursing diagnoses
• Syndrome diagnoses

11. 1. Actual nursing diagnoses describes
human responses to health conditions or
life processes that exist in an individual
,family or community .
• It is the clients actual problem present at
the time of assessment and it is based on
signs and symptoms
• Example : ineffective breathing pattern
• Disturbed sleep pattern

12. 2. A risk nursing diagnoses describes
human responses to health condition or
life processes that may develop in a
vulnerable individual ,family or
community
• It has no subjective or objective cues
Example : risk for infection
• Risk for injury

13. 3. Health promotion nursing diagnosis is
clinical judgement of a person’s ,
family’s or community’s motivation
,desire and readiness to increase well
being and actualize human health
potential as expressed in their readiness
to enhance specific health behaviors such
as nutrition and exercise .

14. • Example : readiness for enhanced
family coping
• Readiness for enhanced self esteem

15. 4. A syndrome diagnosis is a cluster of
signs and symptoms ,which represents
complex clinical conditions requiring
expert nursing assessment and expert
nursing interventions
• Example : rape trauma syndrome ,disuse
syndrome ,post trauma syndrome

16. Components of nursing diagnosis
• It has typically 3 components
• The problem(diagnostic label )/definition
• The etiology and cause
• The defining characteristics

17. 1. Problem
• The problem status describes the client
health status problem or response for
which nursing therapy is given and it
should be specific
• Each diagnostic label approved by
NANDA carries a definition that clarify
its meaning

18. Qualifiers : are words that have been added
to some NANDA label to give additional
meaning to diagnostic statement :
• Deficit chronic
• Impaired imbalanced
• Ineffective interrupted
• Decreased compromised
• Acute high risk

19. 2. Etiology( related factors or risk
factors )
• Identifies one or more probable cause of
the health problem ,give directions to
nursing therapy
Problem
Constipation
Anxiety
Etiology
Long term laxative use ,inactivity and
insufficient fluid intake .
Threat to physiological integrity
possible cancer diagnosis

20. 3. Defining characteristics
• The cluster of signs and symptoms that
indicate the presence of particular
diagnostic label
• Actual diagnosis :client sign and
symptoms
• Risk diagnosis : no subjective signs are
present

21. Formulating diagnostic statement
• One part statement
• Two parts statement
• Three parts statement

22. One part statement
• The diagnostic label are defined and tend
to become more specific ,the interventions
can be derived from the label itself
….etiology may not be needed .
• Syndrome and wellness diagnosis consist
NANDA label only
• Example :Rape trauma syndrome
• Spiritual well being

23. Two parts statement
• 1.problem : statement of clients response
• 2.etiology :factor contributing to or probable
cause of responses
• “ Related to” phrase implies a relationship
• Example :Constipation related to insufficient
fluid intake
• Acute pain related to presence of surgical
incision

24. Three parts statements ( also called as
PES format )
• Problem
• Etiology
• Sign and symptoms
• Actual nursing diagnosis can be
documented by using three part
statement not for risk diagnosis

25. How to write a diagostic statement
related to evidenced by
# patients problem cause /related factor signs and
( etiology ) symptoms
# : priority based ( according to maslow’s hierarchy)
Patient problem or diagnostic label : NANDA approved
statement
Eg: ineffective breathing pattern related to decreased lung
expansion as evidenced by dyspnoea or coughing difficulty

26. Nursing care plan on :
Chronic obstructive
pulmonary disease (COPD)

27. NURSING DIAGNOSIS
1. Ineffective airway clearance related
to excessive mucus production as
evidenced by abnormal respiratory
sound and difficulty in breathing

28. 2. Impaired gas exchange related to
decreased lung function as evidenced by
low oxygen saturation level .
3. Ineffective breathing pattern related to
increased airway resistance as
evidenced by rapid breathing .

29. 4. Imbalanced nutrition , less than body
requirements related to difficulty in
breathing and decreased appetite as
evidenced by poor dietary pattern .
5. Activity intolerance related to shortness
of breath as evidenced by fatigue and
limited physical activity

30. 6. Risk of infection related to weakened
immune system and frequent
respiratory infection as evidenced by
elevated wbc count
7. Knowledge deficit related to lack of
understanding of COPD and its
management as evidenced by patients
questions and concern .

31. 7. Self-care deficit related to limited
ability to perform activities of daily
living as evidenced by difficulty with
grooming and dressing .

32. 9. ineffective coping related to chronic
illness as evidenced by depression and
anxiety .

33. Nursing
assessment
Nursing
diagnosis
Goal/ou
tcome
Planning Rationale Implement
ation
Evaluati
on
Subjective
data : nasal
congestion
,chest pain
,cough
Objective
data :
abnormal
breath
sounds:
wheezing,rh
onchi
Ineffective
airway
clearance
related to
increased
mucus
production
as
evidenced
by
abnormal
respiratory
sound
To
maintai
n
airway
clearan
ce
1 to
Monitor the
vital signs
2.To give
fowlers
position .
3. To give
Steam
inhalation
1.To
identify the
base line
data
2.The
diaphragm
goes down
and there is
enough
space for
the lung to
breathe
3.To
liquefy the
hard mucus
1.Vital
signs are
assessed in
every 4
hourly :
respiration,
pulse ,
2.High
fowlers
position is
given by
fawlers’s
bed
3.Steam
inhalation
is given by
electric
steamer .
Client
maintain
ed clear
airway
upto
some
extent as
verbaliz
ed by
patient
after 12
hours of
intervent
ions

34. Planning
4. To give o2 therapy
if required
5. To perform
Suctioning
6.To give Nebulization
therapy
7. To give Chest
physiotherapy like
breathing and
coughing exercises
Rationale
4.To aid in
breathing
5. To remove
secretions
6.To dilated
bronchus
7.To mobilize the
secretions from
lower respiratory
tract and remove
by coughing
Implementaion
4.o2 is administered to
the patient by simple o2
mask
5.Suctioning is
performed /done in
patient by suction
catheter and wall suction
apparatus
6.Nebulization is given
to patient by duolin for
15 mintues in every
3hourly
7.Breathing exercises
are performed by patient
: pursed lip breathing
exercise and coughing
exercise: controlled
coughing

35. Planning Intervention Implementation
8.Advice to take
lots of fluids
9.Administer
anticholinergic
/expectorants as
prescribed
8.To loosen the
secretions
9.To relieve mucus
formation and
reduce secretions
8.Fluid intake of
patient is incresed
upto 1.5ltr
9. Expectorants are
given to patient
through oral route
(200mg) in every 4
hourly

36. Nursing
assessm
ent
Nursing
diagnosis
Goal/
outcome
Planning Rational
e
Implement
ation
Evaluatio
n
Subjecti
ve data :
Loss of
appetite
,feel
weaknes
s as
verbaliz
es by
patient
Objectiv
e data :
Weight
loss,
poor
dietary
intake
Imbalanced
nutrition
,less than
body
requirement
related to
difficulty in
breathing
,decreased
appetite as
evidenced
by weight
loss
The patient
will achieve
and
maintain
adequate
nutrition
and
hydration
1.To
Assess the
patients
ability to
swallow
and
provide a
modified
diet as
needed .
2to . To
give small
,frequent
meal that
are high in
calories
and
protein.
1.Indicat
or of
nutrition
al
adequac
y of
intake
2.
Smaller
meal
requires
less
effort to
eat and
conserve
energy
1.Patients
ability to
swallowin
g is
assessed
by gag
reflux with
the help of
tongue
depressor
2.Small
amount of
meal and
frequent
meal is
given to
the patient
in every 3
hourly
Nutrition
pattern
improved
up to
some
extent as
verbalized
by patient

37. Planning
3 To provide oral
care before meal
4. To Monitor fluid
intake and
encourage the
patient to drink
fluid between
meals
5. To Administer iv
fluids as prescribed
by the physician
Rationale
3. To
stimulate
appetite
4.These
intervention
s promote
adequate
nutrition and
hydration
Implementa
tion
3 Oral care
is done by
patient
himself
4.Fluid
intake is
monitored
by strict I/O
charting
5.Administ
ered iv
fluids:NS,
DNS ,

38. Assess
ment
Diagnosis Goal
/outco
me
Planning Rationale Evaluation
Subject
ive
data : -
-----
Objecti
ve data
: -------
Risk of
infection
related to
weakened
immune
system
and
frequent
respirator
y
infections
as
evidenced
by
decreased
wbc count
The
patient
will
remain
free
from
all type
of
infecti
ons
1. To
Monitor the
patient for
signs of
infection
and report
any change
in the health
status
2. To Ensure
proper hand
hygiene is
practiced by
all staff and
visitors
1.To
evaluate
presence
and
character
istics of
infection
2.To
prevent
from the
cross
infection
s
After the nursing
intervention the
patient will be free
from further
infection .

39. Planning
3.Provide education
to patient and
family on infection
prevention
techniques
4 to give
prophylactic
medication as
prescribed by
physician
Rationale
3. To reduce the
risk for infection
occurrence
4.To prevent from
the occurrence of
infections
Implementation
3. Health education
is given to patient
and his family
members regarding
hygiene , exercise
,and nutrition
4. Prophylactic
medications is
administered to the
patient : antibiotic
prophylaxis
…gentamycin ( 10
mg /ml )

40. Thank you