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Creating a Nursing Care Plan

Part 1 of the care plan process. Includes description of writing the nursing care plan assigned for PN 101.
by

Amber Schleusner

on 2 November 2017

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Transcript of Creating a Nursing Care Plan

Nursing Process
Assessment/ Diagnosis
Planning
Creating a Nursing Care Plan
Part 1
Assessment
Diagnosis
Planning
Implementing care
Evaluation
Data Collection
Holistic assessment
also includes medical history
Leads to next step
Writing Outcomes
&
Writing nursing interventions
Case Study
73 yr. old main has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” (heart rate is 110 bpm) at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.
Medical Diagnosis


"Difficulty breathing when walking short distances"
"Heart feels like it's racing"
Heart rate 110 bpm
"Tired all the time"

Continually wringing hands
Looking out window
Heart rate 110 bpm
Cluster Symptoms
Chronic Obstructive Pulmonary Disease (COPD)
Analyze
Interpret symptoms...

Subjective or Objective

What are these symptoms indicative of?
"Difficulty breathing when walking short distances"... DYSPNEA
"Heart feels like it's racing"... TACHYCARDIA or DYSRHYTHMIA
"Tired all the time"... FATIGUE
Continually writing hands... ANXIETY
Looking out the window... ANXIETY
Heart rate 110bpm... TACHYCARDIA or DYSRHYTHMIA
Diagnosis
2 ways
Use your symptoms
Use your medical diagnosis

In your Nursing Diagnosis Handbook Section II
Look up the Symptoms your patient has
Under dysrhythmia- 5 possible nursing diagnosis listed
ACTIVITY INTOLERANCE could be used


Note: Not all your symptoms will have the same nursing diagnosis as an option. Also not all of the nursing diagnosis listed will be relevant to your patient

In your Nursing Diagnosis Handbook Section II
Look up COPD
Under COPD the book lists sever possible related nursing diagnosis
ACTIVITY INTOLERANCE & ANXIETY both listed
Use Your Medical Diagnosis
Use Your Symptoms
MAKE SURE YOUR NURSING DIAGNOSIS FITS YOUR PATIENT!!
3 PARTS TO A NURSING DIAGNOSIS
The NANDA LABEL
ex. Activity Intolerance
The etiology or "related to" part
ex. r/t imbalance between oxygen supply and demand
The symptoms or "as evidenced by" part
ex. AEB verbalization of shortness of breath when walking short distances
Read about your Nursing Diagnosis
in Section III
Interventions... are the road map
They direct patient care
Once you have outcomes, your interventions are your method to achieve your outcomes
Choose from NIC listed in
Section III
look under your chosen
nursing diagnosis

Or... Write your own
Criteria for Intervention
5 interventions for each nursing diagnosis
Must be specific
Must be measurable (include verb & a frequency, amount, or time frame
Must have 2 part rationale (with each intervention)
Case Study
Interventions...
Administer patients duoneb treatment as ordered every six hours.

Note: As scheduled every six hours is the frequency part. This makes it measurable
Rationale...
Part I: Nebulized medications can be effective in helping to dilate the airway and break up secretions (Williams & Hopper, p. 606)
Implementing
Care
Evaluation
Writing outcomes
Before you can write outcomes and interventions need to prioritize your nursing diagnosis
Whenever possible should involve client in determining appropriate outcomes
Outcomes must be SMART
Specific
Measurable
Attainable
Realistic
Timed
Case Study
Outcomes
Client will demonstrate increased tolerance to activity by day three as evidenced by appropriate changes in heart rate, BP, and RR during activity
Client will verbalize absence of or decrease in subjective distress by day three
Actual initiation of the care plan
The point at which you actually give nursing care
Perform the interventions that you have written to the client
As interventions are performed make sure they are appropriate for the client
Although listed last, it should be done continually
At the end you would evaluate to see if outcomes were met, if not you have to look at WHY?
Were outcomes smart? Should interventions be changed?
Documentation also important
Part II: My patient had scheduled duonebs which are often ordered for patients with COPD because it helps to clear the airway which can make breathing easier for the patient.
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