Nursing Care planning

Nursing Care planning

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  Prepaired By MubarakRaas
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  3 • Definition  Involvesdetermining before and the strategies or course of actions to be taken before implementation of nursing care. Third step of the Nursing Process NURSING CARE PLANING Prepaired By Mubarak Raas
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  • Nursing careplans are an important part of providing quality patient care. • They help to define the nurses' role in the patient's treatment, • provide consistency of care and allow the nursing to customize its interventions for each patient. • Additionally, it promotes holistic treatment of the patient and helps define specific goals for the patient. • Defining Patient Goals Purpose of Nursing Care Planning Prepaired By Mubarak Raas
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  Steps Of NursingCare Planning Prepaired By Mubarak Raas
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  1. Establish/Set priorities •Priority – It is a decision-making process that ranks the order of nursing diagnosis in terms of importance to the client. Guideline for setting priorities: 1. Life-threatening situations should be given highest priority. 2. Use the principle of ABC’s (airway, breathing, circulation) 3. Use Maslow’s hierarchy of needs. 4. Consider something that is very important to the client. 5. Actual problems take precedence over potential concerns. Prepaired By Mubarak Raas
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  Planning – Beginby prioritizing client problems • Prioritize list of client’s nursing diagnoses using Maslow • Rank as high, intermediate or low • Client specific • Priorities can change Prepaired By Mubarak Raas
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  Activities during Outcome Identification Establishclient’s goals and outcome criteria Client Goal  Is an educated guess made as a broad statement about what the client’s state or condition will be AFTER the nursing intervention is carried out. Planning Developing A Goal And Outcome Statement Prepaired By Mubarak Raas
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  Planning- Types ofgoals Short term goals Short term goal can be achieved in a reasonable amount of time ( few hours to few days) Long term goals Long term goals may take weeks/months to be achieved Prepaired By Mubarak Raas
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  • Short TermGoal (STG) – can be met in a short period (within days or less than a week) • Long Term Goal (LTG) – requires more time (several weeks or months) • Outcome Criteria – are specific, measurable, realistic statements goal attainment. They are written in a manner that they answer the questions: who, what actions, under what circumstance, how well and when. GOALS MAY BE SHORT TERM OR LONG TERM Prepaired By Mubarak Raas
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  Specific Measurable Achievable Relevant Time Bound THE CHARACTERISTICOF WELL-STARED OUTCOME CRITERIA ARE: Prepaired By Mubarak Raas
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  EXAMPLE OF GOALSAND OUTCOME CRITERIA 1. Goal – The client will report a decreased anxiety level regarding Surgery. • Possible Outcome Criteria: • The client discusses fears & concern regarding surgical procedure after client teaching. • After client teaching, the client verbalizes decreased anxiety. • The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience. Prepaired By Mubarak Raas
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  2. Goal –The client will demonstrate safety habits when performing activities of daily living. Possible Outcome Criteria: • Immediately after instruction by the nurse, the client uses call light system for assistance when needs to use the bathroom. • The client demonstrates safety practices when dressing and doing personal hygiene. • The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting out of bed. • The client identifies modification for home safety (removal of throw pillows, installation of hand rails in hallway, better lighting of hallway and stairway), 12 hours after nurse’s instruction about home safety. EXAMPLE OF GOALS AND OUTCOME CRITERIA Prepaired By Mubarak Raas
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  3. Goal –The client will mobilize lung secretions. Possible Outcome Criteria: • After teaching session, the client demonstrates proper coughing techniques. • The client drinks at least 6 glasses of water per day while in the hospital. • The caregiver or significant other demonstrates proper technique of chest physiotherapy including percussion, vibration and postural drainage before discharge. EXAMPLE OF GOALS AND OUTCOME CRITERIA Prepaired By Mubarak Raas
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  Planning-select interventions • Interventionsare selected and written. • The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal. • Interventions should be written clearly and specifically. Prepaired By Mubarak Raas
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  Interventions – 3types • Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision • Dependent ( Physician initiated )-nursing actions requiring MD orders • Collaborative- nursing actions performed jointly with other health care team members Prepaired By Mubarak Raas
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  Bronchial asthma isa disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways. Bronchial asthma is the more correct name for the common form of asthma Example Of Nursing Care Plan Of Patients With Bronchial Asthma Prepaired By Mubarak Raas
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  ASSESSMENT DIAGNOSIS PLANNINGINTERVENTION EVALUATION • Dyspnea • Coughing • Tachypnea • Tachycardia • Chest tightness • Restlessness • Anxiety • Cyanosis • Loss of consciousness • Changes RR Ineffective airway clearance RT bronchoconst riction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough Patient will maintain/improve airway clearance AEB absence of signs of respiratory distress Patient will verbalize understanding that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided. Patient will demonstrate behaviors that would prevent the recurrence of the problem - Administer medications as ordered. - Teach and encourage the use of diaphragmatic breathing and coughing exercises. - Teach early signs of infection that are to be reported to the clinician immediately. - Instruct patient to avoid bronchial irritants such as cigarette smoke - Patient maintains airway clearance AEB absence of signs of respiratory distress - Patient verbalize understanding that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided. Example Of Nursing Care Plan Of Patients With Bronchial Asthma Prepaired By Mubarak Raas
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  Diabetes care plan ClientSituation Mr. S., client with type 2 diabetes (non–insulin-dependent) for 5 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done in the doctor’s office revealed blood glucose of 356, he is admitted to the hospital. Assessment • History of slow healing: lesion L foot, 3 weeks’ duration • Extremities: Numbness/tingling: “My feet feel cold and tingly • like sharp pins poking the bottom of my feet when I walk the quarter mile to the mailbox.” • Cough/character of sputum: occ./white • Change in frequency/amount of urine: yes/voiding more lately • Foot pain Prepaired By Mubarak Raas
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   Nursing Diagnoses impaired Skin Integrity related to pressure, altered metabolic state, circulatory impairment, and decreased sensation, as evidenced by draining wound L foot.  Goal : Blood Glucose Control Possible Outcome Criteria: • Client Will Demonstrate correction of metabolic state as evidenced by FBS less than 120 mg/dL within 36 hr (6/30 0700).  Goal: Wound Healing: Secondary Possible Outcome Criteria: • Client Will Be free of purulent drainage within 48 hr (6/30 1900). Display signs of healing with wound edges clean/pink within 60 hr (discharge) (7/1 0700). Prepaired By Mubarak Raas
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  NURSING INTERVENTION • Irrigatewound with room temperature sterile NS tid. • Assess wound with each dressing change. • Apply wet to dry sterile dressing. • Administer Medications as ordered  Rational • Cleans wound without harming delicate tissues. • Provides information about effectiveness of therapy. • Keeps wound clean/minimizes cross contamination. • Adhesive tape may be abrasive to fragile tissues. • Treatment of infection/prevention of complications. Prepaired By Mubarak Raas
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   Nursing Diagnoses acute Pain related to (open wound L foot), as evidenced by verbal report of pain and guarding behavior.  Goal : Pain Control  Possible Outcome Criteria: • Client will Report pain is minimized/relieved within 1 hr of analgesic administration (ongoing). • Report absence or control of pain by discharge (7/1).  NURSING INTERVENTION • Determine pain characteristics through client’s description. • Place foot cradle on bed; • encourage use of loose-fitting • Administer analgesic as ordered • Document effectiveness. Prepaired By Mubarak Raas
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  Nursing Diagnoses • ineffectiveperipheral Tissue Perfusion related to decreased arterial flow evidenced by decreased pulses, pale/cool feet; thick, brittle nails; numbness/tingling of feet “when walks ¼ mile.”  Goal: Knowledge:  Diabetes client will Verbalize understanding of relationship between chronic disease (diabetes mellitus) and circulatory changes within 48 hr (6/30 1900).  Demonstrate awareness of safety factors/proper foot care within 48 hr (6/30 1900).  Maintain adequate level of hydration to maximize perfusion, as evidenced by balanced intake/output, moist skin/mucous membranes, adequate capillary refill less than 4 seconds (ongoing). Prepaired By Mubarak Raas
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   NURSING INTERVENTION •Elevate feet when up in chair. Avoid long periods with feet dependent. • Assess for signs of dehydration. • Monitor intake/ output. • Encourage oral fluids. • Recommend cessation of smoking. • Discuss complications of disease that result from vascular changes (i.e., ulceration, gangrene, muscle or bony structure changes). Prepaired By Mubarak Raas
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  Nursing Diagnoses  LearningNeed regarding diabetic condition related to misinterpretation of information and lack of recall as evidenced by inaccurate follow- through of instructions regarding home glucose monitoring and foot care, and failure to recognize signs symptoms of hyperglycemia.  Goal: Teaching: Disease Process  Diabetes client will Perform procedure of home glucose monitoring correctly within 36 hr.  Verbalize basic understanding of disease process and treatment within 38 hr.  Explain reasons for actions within 28 hr.  Perform insulin administration correctly within 60 hr. Prepaired By Mubarak Raas
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   NURSING INTERVENTIONS Determine client’s level of knowledge, priorities of learning needs, desire/need for including wife in instruction.  Show film “Living with Diabetes” 6/29 4 PM, when wife is visiting. Include in group teaching session 6/30 AM.  Discuss factors related to/ altering diabetic control (e.g., stress, illness, exercise).  Teach signs/symptoms of hyperglycemia (e.g., fatigue, nausea/vomiting, polyuria and polydipsia).  provide information about necessity for routine examination of feet and proper foot care (e.g., daily inspection for injuries, pressure areas, corns, calluses; proper nail cutting; daily washing, application of good moisturizing lotion Recommend wearing loose-fitting socks and properly fitting shoes (break new shoes in gradually) and avoiding going barefoot. Prepaired By Mubarak Raas
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  Nursing Care Planningfor Hypertension Patient Nursing assessment Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluation Subjective;  Headache, shortness of breath, fatigue, confusion and chest pain Objective  Bp 160/90 mmhg Risk for decreased cardiac output relate d to increased afterload, vasoconstricti on, myocardial ischemia, ventricular hypertrophy Goal: afterload is not increased, there was no vasoconstriction, and myocardial ischemia does not occur. Expected outcomes:  Maintaining blood pressure within an acceptable range.  Showed stable cardiac rhythm and frequency.  Participate in activities that lower blood pressure 1. Monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure. 2. Auscultation of breath sounds and heart tone. 3. Observe skin color, moisture, temperature and capillary refill time. 4. Note the presence, quality of the central and peripheral pulses. 5. Maintain restrictions on activities such as rest in bed or chair. Prepaired By Mubarak Raas
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  Nursing Care Planningfor Hypertension Patient Nursing assessmen t Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluatio n Subjective;  Headache, shortness of breath, fatigue, confusion and chest pain Objective  Bp 160/90 mmhg 2. Acute pain: headache related to increased cerebral vascular pressure. Goal: The pressure does not increase cerebral vascular Expected Outcomes: Patients revealed the absence of headache and looked comfortable. 1. Maintain bed rest, quiet neighborhood, a little light. 2. Limit of patients in the activity. 3. Minimize disruption and environmental stimuli. 4. Give a fun action according to indications such as ice packs, the position of comfort, relaxation techniques, counseling 5. Medical collaboration in providing analgesic and sedative drugsPrepaired By Mubarak Raas
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  RHEUMATOID ARTHRITIS Rheumatoid Arthritisis a chronic inflammatory disorder that typically affects the small joints in your hands and feet. Unlike the wear-and-tear damage of Osteoarthritis, Rheumatoid Arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity. As an autoimmune disorder, Rheumatoid Arthritis occurs when your immune system mistakenly attacks your own body’s tissues. In addition to causing joint problems, Rheumatoid Arthritis sometimes can affect other organs of the body — such as the skin, eyes, lungs and blood vessels. Prepaired By Mubarak Raas
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   Signs andSymptoms of Rheumatoid Arthritis May Include:  Tender, warm, swollen joints  Morning stiffness that may last for hours  Firm bumps of tissue under the skin on your arms (rheumatoid nodules)  Fatigue, fever and weight loss Causes of Rheumatoid Arthritis? The actual cause of RA is unknown, but it is thought to be triggered by environmental factors, such as infections with viruses or bacteria, in people with a genetic predisposition to the disease. RHEUMATOID ARTHRITIS Prepaired By Mubarak Raas
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  Nursing Care Planningfor RHEUMATOID ARTHRITIS Patient Nursing assessment Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluation Subjective Pain Objective: N/A Problem Chronic Pain R/T Progression of joint deterioration , injury, surgical procedure, and chronic kidney disease AEB as evidenced by patient self report of pain level. Long Term: Client will function on acceptable ability level with minimal interference from pain and medication side effects two months. Short Term: Use pain rating scale to identify current level of pain intensity, and determine comfort/function goal. 1. Tell the client to report pain location, intensity and quality when experiencing pain. Assess and document the intensity of the pain with each new report of pain and at regular intervals. Systemati c ongoing assessment and documentation provide the direction for pain treatment plans ; adjustments are based on the client’s response. The pt stated that his pain scale is 2 Prepaired By Mubarak Raas
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  Parkinson's Disease Parkinson's diseaseis one of a larger group of neurological conditions called motor system disorders. In the normal brain, some nerve cells produce the chemical dopamine, which transmits signals within the brain to produce smooth movement of muscles. In Parkinson's patients, 80 percent or more of these dopamine-producing cells are damaged, dead, or otherwise degenerated. This causes the nerve cells to fire wildly, leaving patients unable to control their movements. Symptoms usually show up in one or more of four ways: • tremor, or trembling in hands, arms, legs, jaw, and face • rigidity, or stiffness of limbs and trunk • bradykinesia, or slowness of movement • postural instability or impaired balance and coordination. Prepaired By Mubarak Raas
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  Symptoms of Parkinson'sDisease • Tremors- the most noticeable early symptom. It often begins very localised, such as in a finger of one hand. Over time it spreads throughout the whole arm. Tremors often occur when the limb is at rest or when held in a stiff, unsupported position. Tremors also may occur in the lips, feet or tongue. • Bradykinesia- slowness of motion. The individual's movements become increasingly slow and over time muscles may randomly "freeze". • Akinesia- muscle rigidity. Often begins in the legs and neck. • Digestion problems- the ability to process food slows down, resulting in low energy and constipation. • Depression- Parkinson's causes chemical changes in the brain that may result in depression. • Low Blood Pressure- can result in light headedness and fainting. • Temperature sensitivity- perception of temperature can be affected, and may result in hot flashes and excessive sweating. Prepaired By Mubarak Raas
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  Nursing Care Planningfor Parkinson's Disease Patient Assessment diagnosis planning intervention evaluation Subjective client said it was difficult to do activities Pt demonstrates difficulty with any movement of the left lower extremity. Objective Pt states that his pain level is a 9 on a 10-point pain rating scale. Pt grimaces during any kind of motion or movement of his left lower extremity Problem: Impaired physical mobility related to muscle stiffness and tremors AEB Grimacing during movement or activity Pt complaints about pain and discomfort Pt pain rating of 9 out of 10 Long Term: Pt will be able to ambulate around the nurses’ station 2X by discharge. Short Term: Pt will perform passive range of motion exercises by the end of this shift. Apply any ordered brace before mobilizing the client. Increase independence in ADLs Obtain any assistive devices needed for activity. Assess the pt’s pain by using the 10-point pain rating scale q4 hrs. or PRN. Before activity, treat pain. Goal met. Pt was able to ambulate around the nurses’ station by discharge. Pt was able to complete his activity more than twice. Pt did not complain of any pain or discomfort upon ambulation. Pt states “I feel like I’m finally getting back to my old self.” Goal met. Pt able to fully complete passive range of motion exercises with assistance from the staff by the end of this shift. Pt did not complain of any pain associated with exercise session. Prepaired By Mubarak Raas
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  Alzheimer’s disease Alzheimer’s diseaseis a progressive and irreversible, degenerative, fatal disease and is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities. It usually begins after age 60 and the risk goes up as you get older. Risk is also higher if a family member has the disease. Progression of the disease is done in phases until all cognitive function is destroyed. Pathologic consequences include the loss of neurons in multiple areas within the brain, atrophy with wide sulci and dilated ventricles of the brain, the presence of plaques composed of neurites, astrocytes, and glial cells that surround an amyloid center, and neurofibrillary tangles. Symptoms seen in AD are the result of the destruction of numerous neurons in the hippocampus and the cerebral cortex. The enzyme choline acetyltransferase, has a decreased action with AD patients, which results in impaired conduction of impulses between the nerve cells caused by lack of acetylcholine production. Currently, no treatment can stop the progression of the disease. However, some drugs may help keep symptoms from getting worse for a limited time Prepaired By Mubarak Raas
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  NR Assessment NRDiagnosis NR Planning NR Intervention NR Evaluation Disorientation to time, and place. Decreased ability to reason or conceptualize Inability to calculate Memory loss Inability to follow Dysphagia Convulsions Inappropriate social behavior Paranoia Combativeness 2. Chronic Confusion related to Alzheimer’s disease Possibly evidenced by Decreased ability to interpret one’s environment Decreased capacity for thought Altered interpretation Patient will have minimal confusion, cognitive impairment, and other dementia manifestations. Patient will have stable, safe environment with routine scheduling of activities to decrease anxiety and confusion. Maintain consistent scheduling with allowances for patient’s specific needs, and avoid frustrating situations and overstimulation. Assists patients with early AD to remember location of articles and facilitates some orientation. Instruct family regarding avoidance of arguing with patient about what he thinks, sees, or hears. The Patient maintains minimal confusion, cognitive impairment, and other dementia manifestations. The Patient demonstrates stable, safe environment with routine scheduling of activities to decrease anxiety and confusion. Prepaired By Mubarak Raas
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  Nursing Care Planfor Preeclampsia Preeclampsia is a collection of symptoms that occur in pregnant women, maternity and childbirth consisting of hypertension, edema and proteinuria, but show no signs of vascular abnormalities or hypertension before, while the symptoms usually appear after age 28 weeks gestation or more. Clinical manifestations Signs of preeclampsia usually arise in the order • excessive weight gain, edema, hypertension, and proteinuria occur. • Subjective symptoms: headache frontal area, epigastric pain; impaired visual acuity; blurred vision, scotoma, diplopia; nausea and vomiting. • Other cerebral disorders: increased reflexes, and not quietly. • Examination: high blood pressure, reflexes increased and proteinuria in the laboratory. Prepaired By Mubarak Raas
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  Nursing Care Planningfor Preeclampsia Patient Nursing assessment Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluation Subjective headache, epigastric pain; blurred vision, nausea and vomiting. Examination: high BP, Edema and proteinuria in the laboratory. Problem Ineffective Tissue Perfusion: cerebral, renal, cardiac R/T impaired circulation. AEB high BP Gaoals: The circulation of the body is not impaired. Expected outcomes Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headache, dizziness, Stable vital signs. Urine output 30 ml / min. 1. Maintain bed rest, 2. Measure the input and discharge. 3. Observe the sudden hypotension. 4. Monitor electrolytes, creatinine according to medical advice. 5. Maintain fluids and medications according to medical advice. Prepaired By Mubarak Raas
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  Nursing Care Planningfor Preeclampsia Patient Nursing assessmen t Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluatio n Subjective;  Headache, shortness of breath, fatigue, confusion and chest pain Objective  Bp 160/90 mmhg 2. Acute pain: headache related to increased cerebral vascular pressure. Goal: The pressure does not increase cerebral vascular Expected Outcomes: Patients revealed the absence of headache and looked comfortable. 1. Maintain bed rest, quiet neighborhood, a little light. 2. Limit of patients in the activity. 3. Minimize disruption and environmental stimuli. 4. Give a fun action according to indications such as ice packs, the position of comfort, relaxation techniques, counseling 5. Medical collaboration in providing analgesic and sedative drugsPrepaired By Mubarak Raas
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  Nursing Care Planfor Placenta Previa Placenta Previa is abnormally located placenta, which is on the lower uterine segment so as to cover part or all of the opening of the birth canal. The exact cause of placenta previa is unknown. But the reduced vascularity in the lower uterine segment due to uterine scar surgery, molar pregnancy, or tumors may cause Placenta Previa Clinical Symptoms  Bleeding without pain, gestational age over 22 weeks.  The presence of anemia and shock in accordance with the discharge of blood. Physical examination  External examination of the presenting part is usually not entered the pelvic inlet.  No abnormalities of the pelvic location of the fetus.Prepaired By Mubarak Raas
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  Nursing Care Planningfor Placenta Previa Patient Nursing assessment Nursing diagnosis Nursing care planning Nursing intervention Nursing Evaluatio n  Bleeding without pain, gestational age over 22 weeks.  Recurrent bleeding.  The presence of anemia and shock in accordance with the discharge of blood.  Palpable placental tissue in the vagina. Risk Fluid Volume Deficit related to excessive bleeding due to abnormal placental implantation, AEB Recurrent bleeding  Goal:  Fluid volume needs of clients are met.  Expected Outcomes:  Clients can indicate stability / improvement of fluid balance as evidenced by stable vital signs, capillary refill quickly, as well as expenses and adequate urine specific gravity individually. 1. Evaluation, report, and record the number and nature of blood loss. 2. Do bed rest. 3. Position the mother with the right, with the pelvis elevated supine or semi- Fowler position. 4. Monitor uterine activity, fetal status, and presence of abdominal tenderness. Prepaired By Mubarak Raas