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Nursing care plan
- 1. Presented by :Akshitanegi ( Bsc. Nursing 2nd Sem ) Nursing process
- 2. Nursing process Nursing processis 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 nursingprocess Nursing process is a systematic series of 5 steps these are : • Assessment • Nursing diagnosis • Outcome / planning • Implementation • Evaluation
- 4. Steps of nursingprocess
- 5. 1. Assessment • Assessmentis the first step of the nursing process .It involves the use of critical thinking skills for data collection : • Subjective data • Objective data
- 6. • Subjected dataare 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 :elevatedtemperature 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 nursingdiagnosis • 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 nursingdiagnoses 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 risknursing 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 promotionnursing 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 syndromediagnosis 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 nursingdiagnosis • It has typically 3 components • The problem(diagnostic label )/definition • The etiology and cause • The defining characteristics
- 17. 1. Problem • Theproblem 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 : arewords 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( relatedfactors 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 writea 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 planon : Chronic obstructive pulmonary disease (COPD)
- 27. NURSING DIAGNOSIS 1. Ineffectiveairway clearance related to excessive mucus production as evidenced by abnormal respiratory sound and difficulty in breathing
- 28. 2. Impaired gasexchange 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 ofinfection 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 deficitrelated to limited ability to perform activities of daily living as evidenced by difficulty with grooming and dressing .
- 32. 9. ineffective copingrelated 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 giveo2 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.Adviceto 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 provideoral 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 RationaleEvaluation 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 patientand 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.