Appendix
Individualized Care Plans Fully Developed
A
Refer to Chapter 1 “The Nursing Process: A Synopsis,” p. 32: Two Individualized Care Plans Fully Developed; Care Plan 1 for Mr. John Walters, Care Plan 2 for Mrs. Mary Smith. All nursing actions and behaviors (nursing interventions) should focus on the individual client’s assessment. How can you be certain that the assessment in the completed care plan for Mr. John Walters focused on the physical examination, interview, and data collected from the client’s chart? Activity 1 Examine the ordered and selected data for Mr. Walters (first column of Individualized Care Plan 1). a. Physical examination (objective data) nonverbal behavior, attentive (body posture) demonstrates genuine concern for knowledge (readiness to learn). b. Interview (subjective data) client states, “I have no idea what to do about this condition.” c. Data collected from the client’s chart: medical diagnosis—Hemorrhoidectomy (first postoperative day).
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Appendix A
How can you be certain that the nursing diagnosis is formulated from what the client says (the subjective data) and what is found during the physical assessment (objective data) and that the nursing diagnosis is named from the NANDA list as it applies to Mr. Walters? Activity 2 Look again at the ordered/selected column and notice that the client is saying that he does not know how to care for his condition and that his nonverbal communication (objective data) confirms his desire for knowledge. Now examine the NANDA list of nursing diagnoses (p. 169) and observe that the diagnosis that relates to lack of knowledge is Knowledge, Deficient. Be sure to relate this diagnosis to the specific information that your client is seeking (read the diagnosis as written in Individualized Care Plan 1). How do you know when your defining characteristics are correct? Remember that the defining characteristics should substantiate your nursing diagnosis and at least three should match your objective subjective data. Activity 3 Examine the defining characteristics in the completed Individualized Care Plan 1. Notice that three characteristics correspond with the objective/subjective data: voiced lack of knowledge, demonstrated readiness to learn, and asked questions. How do you know that the goals relate specifically to Mr. Walters and that they are attainable? Activity 4 Examine the goals column in the care plan for Mr. Walters. Notice that the short-term goal has the client answering the very questions he asked and the long-term goal has him doing what he needs to do in order to care for himself. How do you know that the interventions involve both client and nurse? Activity 5 Examine the nursing interventions for Mr. Walters. Notice that they are quite comprehensive: details are explained to him, the nurse demonstrates the procedures, and he is given the opportunity to perform these tasks. Activity 6 Examine the rationale column of the completed care plan for Mr. Walters. Notice that there is a rationale (a reason) for each intervention but that these can be used for any client with similar nursing interventions.
Appendix A
Were the stated goals realized for Mr. Walters? Activity 7 Examine the evaluation column of the completed care plan for Mr. Walters. Note that the client now understands what to do (both short term and long term). The long-term results show him performing the procedures he was taught by the second day and repeating what to do while in the hospital and at home (goal met). Activity 8 Examine Care Plan 2 the same way you did for Care Plan 1 and you will realize that Care Plan 2 is sequential and individualized to the 84-year-old client with a nursing diagnosis of Risk for Impaired Skin Integrity.
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4 CLIENT: Mr. John Walters AGE: 50 Ordered & Selected Data Subjective data: Client states “I have no idea what to do about this condition; what do I do?” Objective data: Nonverbal behavior demonstrates genuine concern for knowing— attentive, expectant (readiness to learn).
Individualized Care Plan 1 for Appendix A Knowledge Deficit MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
Knowledge deficit about self-care after hemorrhoidectomy evidenced by client’s statement and nonverbal behavior (see ordered & selected data.
Short term: Client will verbalize understanding of the things he needs to do on the first operation day between 0800 and 1000.
Teach the client the following • This procedure will cause much pain.
• Understanding of underlying principles of care fosters cooperation and decreases anxiety. The rectum is very vascular, bleeds easily, and causes much pain. • Client comfort is a priority with the nurse. Suffering is contradictory to good nursing care. • Enhances comfort and aids healing. Water is a cleaning agent that also prevents accumulation of bacteria. • Provides a soft cushion. Client should not be left alone because of the potential for fainting after general anesthesia, NPO state, decreased food and fluid intake, and possible blood loss.
Short term goal met: Client interacted in the teaching session, stated, “I will do those things.”
Defining characteristics: • Voices lack of knowledge • Demonstrates readiness to learn (attentive, expectant) • Reluctant to touch affected area. • Asks questions about the condition.
Long term: Client will demonstrate techniques that need to be performed in the hospital and at home on the second postoperative day.
• Medication is available every 3 hours and should be taken on days 1 and 2 after surgery. • Sitz baths are necessary and should begin the first day after surgery.
• A rubber ring will be placed in the bathtub and he will sit on it. The nurse will be in attendance.
Long term goal met: Self care on second day with little assistance. Rehearsed the things to report while in the hospital and after going home.
continues
CLIENT: Mr. John Walters AGE: 50 Ordered & Selected Data
Nursing Diagnosis
Individualized Care Plan 1 for Appendix A Knowledge Deficit (continued) MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day) Goals
Interventions
Rationale
• A packing is in his rectum, which will be removed the second morning. • He is to continue to wear the T-binder and will be provided with a clean one as needed. • He should ask for pain medication before he has a bowel movement. • His oral medication will keep his stool soft. An oil retention enema (to soften stool) may be given on day 3 if he does not have a bowel movement. He should eat higher fiber foods. • The area should be thoroughly washed after every bowel movement.
• Aids in the absorption of drainage (bloody or serosanguinous). • Keeps dressing in place and avoids contamination of wound. • Decreases actual pain and anxiety related to first bowel movement. • Colace to be given routinely as a stool softener. Oil retention enema concentrates in lower bowel and rectum and facilitates passage of soft stool. • Bleeding, infection, and pain are still possible complications while in the hospital and after discharge.
Evaluation
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6 CLIENT: Mrs. Mary Smith AGE: 84 Ordered & Selected Data Subjective data: Client states “I am skin and bones.” Objective data: Skin dry and intact, warm to touch Height: 5 feet, 3 inches Weight: 95 pounds Ideal body weight: 127 pounds Evidence of muscle wasting.
Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity MEDICAL DIAGNOSIS: Severe weight loss
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
Risk for impaired skin integrity.
Short term: Client’s skin will show no signs of impairment between 0700 and 1500, on 09/06/03.
Discuss the plan of care and the rationale for each action with the client (solicit cooperation).
Understanding of the medical and nursing regimen will enhance client’s cooperation.
Short-term goal met: Client stated, “I know how it is to get a bedsore. I have had them before; I surely do not want any more.”
• Turn every two hours • Remove sheering forces at least every 4 hours (tighten draw sheet, remove debris). • Gently insert bedpan.
• Sheering forces against the skin will cause irritation and alter the integrity on the first defense (skin).
• Change linen if accidents (wet spots) occur.
• Moisture encourages bacterial growth, causing damage and infection to tissue.
Defining characteristics: Risk factors • Immobility • Moisture (diaphoresis) • Variations in temperature (very hot or very cold) • Malnourished • Age (elder) • Impaired circulation • Poor skin turgor • Trauma (sheering forces: bed sheets, bedpan) • Neurological deficits (impaired sensation)
Long term: Client’s skin will remain intact on 09/07/03.
No evidence of redness or irritation on day 1.
Long-term goal met: No alteration in skin integrity. Staff asked to continue the regimen begun by the student nurse.
continues
CLIENT: Mrs. Mary Smith AGE: 84 Ordered & Selected Data
Nursing Diagnosis
Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity (continued) MEDICAL DIAGNOSIS: Severe weight loss Goals
Interventions
Rationale
• Daily bath and thorough cleansing after urination and defecation.
• Daily hygienic measures eliminate odors and prevent infections.
• Ambulation at least twice daily.
• Activity (exercise) improves the functioning of all organ systems.
• Increase fluid intake daily (start with 2 glasses and increase to 8 daily) • Select foods that have high vitamin, high protein, and high carbohydrate content. • Endeavor to eat as much as possible (include midmorning and evening snacks).
• Proper nutrition strengthens the immune system and helps to maintain a healthy state. Fluids bathe body tissue, remove waste and aid in fluid balance.
Evaluation
Reference: Cox, H.C., Hinz, M., Lubno, M. Scott-Tilley, D., Newfield, S., Slater, M., & Sridaromont, K. (2002). Clinical applications of nursing diagnosis. Philadelphia: F.A. Davis.
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