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Transcript
Running head: DEVELOPING A CARE PLAN
Developing a Care Plan
Valerica Marta
NorQuest College
NFDN-1001-Nursing Foundations
Assignment 2: Nursing Process / Care Plan
Cindy Hoyme
June 23, 2015
1
DEVELOPING A CARE PLAN
2
Developing a Care Plan
Introduction
The purpose of this paper is to develop a care plan based on a given scenario, using the
nursing concepts and the nursing process.
The paper will also examine the benefits and importance of the nursing process, the
benefits of using nursing concepts and the benefits of using SMART criteria when setting up
goals.
The five steps of the nursing process are also briefly discussed.
Step 1: Nursing Assessment Form
The Nursing Assessment form is shown in Appendix A.
Step 2: Nursing Diagnosis Form
The Nursing Diagnosis form is shown in Appendix B.
Step 3: Nursing Care Plan
The Nursing Care Plan form is shown in Appendix C.
Summary
The Benefits and Importance of Nursing Process
The nursing process provides an organized framework for meeting the individual needs
of the client, the client’s family / significant other(s), and the community.
The nursing process provides an organized, systematic method of problem-solving that
may minimize dangerous errors or omissions in care giving and avoid time-consuming repetition
in care and documentation. The use of the nursing process promotes the active involvement of
clients in their health care, enhancing consumer satisfaction. Such participation increase client’s
sense of control over what is happening to him, stimulates problem-solving, and promotes
DEVELOPING A CARE PLAN
3
personal responsibility, all of which strengthen the client’s commitment to achieving the
identified goals (Nursingprocess.org, n.d.)
The use of the nursing process enables the nurses to have more control over the practice.
It also provides a common language (nursing diagnosis) for practice, unifying the nursing
profession. Using a system that clearly communicates the plan of care to co-workers and clients
enhances continuity of care, promotes achievement of client goals.
In essence, the nursing process is important because it provides a methodical approach to
examine patient’s problems and identifies ways of resolving these problems.
The Benefits of Using Nursing Concepts
Metaparadigm: - a metaparadigm is the most global perspective of a discipline and “acts
as an encapsulating unit, or framework, within which the more restricted .... structures develop”
(Eckberg & Hill, 1979, p.927)
The central concepts of the discipline of nursing are person, environment, health and
nursing. Conceptual models provide a comprehensive view and scope for practice. The
metaparadigm concepts serve to guide assessment intervention and evaluation of nursing care.
They provide a rationale for collecting reliable and valid data about health states of clients,
which are essential for decision making and implementation. They help to establish criteria to
measure the quality of nursing care. (Masters, 2015)
The Benefits of Using SMART Criteria
SMART goals are beneficial for a multitude of reasons. They are not vague, and because
of their specificity, you can know tight away if you are on track. Progress is easy to monitor,
SMART goals make easier and quicker to identify missed targets and therefore you can react
faster to make changes to your activities to accommodate your goals. Large goals seem too big to
DEVELOPING A CARE PLAN
4
handle, but breaking them down into lots of small goals makes change easier. Small, immediate
goals are easier to see and achieve.
The Five Steps of the Nursing Process
Step 1: Assessment Phase
During this phase, the nurse gathers information about a patient’s psychological,
physiological, sociological and spiritual status, usually during an interview with the patient.
Physical examination, referencing patient’s health history, obtaining patient’s family history and
general observation can also be used to get assessment data. Patient interaction is generally the
heaviest during this phase. The main requirement of accurate assessment is to view patients
holistically and identifying their real needs.
Step 2: Diagnosing Phase
During this phase a nurse makes an educated judgement about a potential or actual health
problem with a patient. Multiple diagnoses are sometimes made for a single patient. Nursing
diagnoses are different from medical diagnoses because they address patient’s problems that
result from the disease process while clinical diagnoses focus on the disease process alone. This
phase is important because it serves as a basis for selection of interventions and the subsequent
achievement of patient outcomes (Lunney, 2008).
Step 3: Planning phase
During this phase, a plan of action is developed. Each problem is assigned a clear,
measurable goal for the expected beneficial outcome. Nurses generally refer to the evidence –
based Nursing Outcome Clarification, which can also be used as a resource for planning (Keenan
et al, 2008).
Step 4: Implementing Phase
DEVELOPING A CARE PLAN
During this phase the nurse follows through on the decided course of action. Actions
involved in a nursing care plan include monitoring the patient for signs of change or
improvement, directly caring for the patient or performing necessary medical tasks, educating
and instructing the patient about further health management and referring or contacting the
patient for follow-up. Implementation can take place over the course of hours, days, weeks or
even months.
Step 5: Evaluation phase
During this phase, the nurse completes an evaluation to determine if the goals for
patient’s wellness have been met. The possible patient outcomes are generally described under
three terms: patient’s condition improved, patient condition stabilized and patient’s condition
deteriorated, died or discharged. If the patient’s condition has shown no improvement, or if the
wellness goals were not met, the nursing process begins again from the first step.
5
DEVELOPING A CARE PLAN
6
Appendix A
Step 1: Nursing Assessment Form
Client Name: Jane Doe
Medical Diagnosis: Asthma
Client Perception of Health Needs: Eat healthy on a student budget
Client Goals for Health: Coping with stress, adequate sleeping during the night
Allergies
(food, medication,
environmental)
Medications
Dietary
considerations
Shellfish
Ventolin
When dining out, avoid seafood restaurants; in regular restaurants, exert caution with
fried foods, as some restaurants use the same oil to fry shrimp, chicken and French
fries.
HEALTH ASSESSMENT DATA
Fill in data from the scenario
Client
Ms. Doe is a 19 years old woman who is finding difficult to juggle her responsibilities and is feeling
very anxious.
Ms. Doe is a student in the PN program, and has a part-time job at SportCheck.
Client recently moved from New Brunswick to Alberta, leaving behind mother, father and two younger
siblings.
Client is allergic to shellfish, and was diagnosed with asthma as a child. Her medication list is composed
of Ventolin puffers, taken occasionally.
Health
The patient was diagnosed with asthma when she was a child. She is using Ventolin puffers
occasionally when needed; no other scheduled medication.
The client is allergic to shellfish.
She is feeling very anxious.
DEVELOPING A CARE PLAN
7
HEALTH ASSESSMENT DATA
Spiritual Variable (Environment)
Developmental Variable (Environment)
The client does not reveal any of her spiritual
beliefs.
Client is a 19 years old female, who moved from
New Brunswick to Alberta, to study in the PN
program.
In New Brunswick she left behind her family, but
in Alberta she has a boyfriend.
Client has a retail part-time job.
Sociological Variable (Environment)
The client is a student in a PN program while
taking English courses. She is in a
relationship. The client moved from New
Brunswick to Alberta, while the rest of her
family stayed in New Brunswick.
She has a part-time job at SportCheck.
Psychological Variable (Environment)
The client is feeling pressured from school,
work and boyfriend.
She has difficulty to juggle with her
responsibilities.
She is feeling very anxious.
Determinants of health impacting client’s health (Environment)






Income and social status (low income)
Social support network
Employment and working conditions
Physical environments
Individual health practices and coping skills
Social environments
Health Priorities as determined by the Nurse and Client





Mental and emotional health (coping with stress)
Eat a balanced diet (health improvement by eating healthy)
Maintain a regular schedule of sleeping (sleeping during the night)
Physical health
Connect with others
Client Strengths as determined by the Nurse and Client
The client is young (19 years old).
Her asthma condition is kept under control (she uses Ventolin just occasionally when needed).
She does not have any other regularly medication.
DEVELOPING A CARE PLAN
8
Appendix B
Step 2: Nursing Diagnosis
Write three (3) nursing diagnoses – one actual, one potential, and one wellness behaviour – that
include the following:

NANDA approved nursing diagnosis statement - Reference to a client strength or health need

Cause/ Contributing factors (related to)

Symptom/ Presenting evidence (as evidenced by)

Actual Nursing Diagnosis
Coping, Ineffective Individual: “she is finding difficult to juggle all of the responsibilities and is
feeling very anxious”.
Cause:
 She has one month left to complete her coursework (PN program).
 Self- pressured to finish buying presents for family and friends.
 Difficulty maintaining her part-time job at SportCheck.
 Working 3 12-hours shifts in the clinical settings.
 Taking an English course one evening per week.
 Trying to complete a scholarly paper.
 Pressure from boyfriend to spend more time with him.
 Two of her peers called in sick complaining of vomiting and diarrhea after she spent
time with them the previous afternoon in a study group.
Symptoms:
Anxiety – “feeling very anxious”
DEVELOPING A CARE PLAN
Potential Nursing Diagnosis
Imbalanced Nutrition: less than body requirements.
Cause:
 Inability to acquire or prepare food
 Inadequate knowledge about essential nutrients and balanced diet
 Eating take-out pizza and coffee to keep herself going
Symptoms:
 The intake of nutrients is insufficient to meet metabolic needs.
 Brahicardia, cardiac irregularities, hypotension, decreased tolerance for activity,
weakness, loss of weight, fatigue.
Wellness Nursing Diagnosis
Sleep Deprivation
Cause:
 Client has to complete her coursework (PN program);
 Study for finals – she has been up several nights trying to complete a scholarly paper
and is having difficulty writing it.
Symptoms:
Lack of sleep can lead to fatigue, jitters and stress because your body does not get adequate
time to repair itself each night.
9
DEVELOPING A CARE PLAN
10
Appendix C
Step 3: Nursing Care Plan
Coping, Ineffective Individual.
PRIORITY NURSING
DIAGNOSIS
Definition: Impairment of adaptive behaviours and problem-solving abilities of a person in meeting life’s demands and
roles.
For most persons, everyday life includes its share of stressors and demands, ranging from family, work and professional
role responsibilities to major life events.
How one responds to such stressors depends on their coping resources.
CLIENT GOAL
Write one specific and
measurable client behavioural
response.
CLIENT -CENTRED
OUTCOME
Write statements in
measurable terms that support
the goal by using the
SMART criteria:
 Specific
 Measurable
 Attainable
 Realistic
 Time-based
Client will demonstrate ability to cope effectively to stressors measured by utilization of two new stress reducing skills
in 5 days.
Client will assess the current situation accurately and will identify ineffective coping behaviours and consequences.
The client will identify at least two new coping strategies within 5 days.
The client will identify two support systems within 5 days.
DEVELOPING A CARE PLAN
IDENTIFY 3 NURSING
INTERVENTIONS
Select nursing interventions
to meet the goals set, and to
change or maintain health
status
RATIONALE FOR
INTERVENTIONS
Provide rationale for
selection of nursing
interventions and use
appropriate literature such as
text, articles, and internet
sites to support internet sites
to support choices
1) The nurse will collaborate with
the client to identify personal
strengths.
The nurse will observe for causes
of ineffective coping, such as: poor
self-concept, lacking of problemsolving skills, lack of support, or
recent change in life situation.
11
2) The nurse will teach use of
relaxation, exercise and diversional
activities as methods to cope with
stress.
The nurse will encourage use of
cognitive behavioural relaxation
(e.g. music therapy, guided
imagery).
During crisis, patients may not be able
to recognize their strengths.
Problem solving skills promote the
client’s sense of control.
Recognition of personal strengths
identifies a person’s values and
beliefs.
Relaxation decreases stress and
enhanced coping
Encourage patient to identify own
strengths and abilities.
Situational factors must be identified
to gain an understanding of the client’s
current situation and aid client with
coping effectively
(nursinginterventionsrationales.
blogspot.ca).
Listening to music has been found to
decrease total mood disturbances
scores (profile of mood states [POMS]
scores).
A decrease in POMS scores is
indicative of decreased distress and a
mood improvement
(nursinginterventionsrationales.
blogspot.ca).
Using process imagery, a person can
look at an old problem in a totally
different way, making new connections
and freeing the problem from the
original memory. Imagery “engenders
3) The nurse will refer the client
for counselling as needed, or refer
client to support groups.
The nurse will teach client about
available community resources
(e.g. therapists, ministers,
counsellors, self-help groups).
The nurse will evaluate resources
and support systems available to
client.
Arraigning for referral assists the
client in working with the system,
and resource use helps to develop
problem-solving and coping skills
(Feeley, Gottlieb, 1998).
Support groups foster the sharing of
common experiences and help build
mutual support. They are particularly
helpful when others within the
family are unable to provide support.
(Mead, Hilton and Curtis, 2014).
Praying and religion are frequently
used effective coping strategies
(Young, Koopsen, 2005).
Resources may include significant
others, healthcare providers, such as
home-health nurses, community
resources, spiritual counselling.
DEVELOPING A CARE PLAN
12
a feeling of control and gives the client
effective tools for self-care” (Stephens,
1993).
EVALUATION
Describe how you plan to
evaluate if the goal was met
or not met.
If the client identifies two new coping strategies within 5 days, the goal is considered met.
If the client identifies two support systems within 5 days, the goal is met.
If the client does not feel anxious anymore and will assess the situation accurately, the goal is met.
DEVELOPING A CARE PLAN
13
References
Eckberg, D. L. & Hill, L. Jr. (1979). The paradigm concept and sociology: A critical review.
American Sociological Review, 44, 925–937.
Feeley, N., & Gottlieb, L.N. (1998). Classification systems for health concerns, nursing
strategies and client outcomes: Nursing practice with families who have a child with a
chronic illness. Canadian Journal of Nursing Research, 30, 45–59.
Keenan, G.M., Yakel, E., Tshannen, D., Mandeville M. (2008). Documentation and the Nurse
Care Planning Process. In Hughes RG, editor. Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and
Quality (US); 2008 Apr. Chapter 49. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK2674
Lunney, M. (2008). Critical Need to Address Accuracy of Nurses’ Diagnoses. In The Online
Journal of Issues in Nursing, vol. 13 – 2008. Retrieved from http://nursingworld.org/
mainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol1320
08/No1Jan08/ArticlePreviousTopic/AccuracyofNursesDiagnoses.html
Masters, K. (2015). Framework for Nursing Practice. Retrieved from
http://samples.jbpubs.com/9781449691509/81982_CH02_Pass1.pdf
Mead, S., Hilton, D., Curtis. L. (2014). Peer Support: A theoretical Perspective. Retrieved from
http://www.intentionalpeersupport.org/wp-content/uploads/2014/02/Peer-Support_ATheoretical-Perspective.pdf
nursinginterventionsrationales.blogspot.ca (n.d.) Ineffective Coping. Retrieved from
http://nursinginterventionsrationales.blogspot.ca/2013/07/ineffective-coping.html
DEVELOPING A CARE PLAN
14
Nursingprocess.org (n.d.) The 5 Steps of the Nursing Process. Retrieved from
http://www.nursingprocess.org/Nursing-Process-Steps.html
Stephens, R. (1993). Imagery: a strategic intervention to empower clients. Part I--Review of
research literature. In Clinical Nurse Specialist. 1993 Jul;7(4):170-4. Review.
Study.com (n.d.) Nursing 101: Fundamentals of Nursing Course. Retrieved from
http://study.com/academy/lesson/nursing-process-purpose-and-steps.html
Young,C., Koopsen, C. (2005). Spirituality, Health, and Healing. Retrieved from
https://books.google.ca/books?id=wZW7snWf_JwC&pg=PA231&lpg=PA231&dq=Pray
ng+and+religion+are+frequently+used+effective+coping+strategies&source=bl&ots=GQ
uDbx9ACH&sig=AhTRR07zhtJi1oee7qFNSdsO0A&hl=en&sa=X&ei=ZKiIVcamJ833oAS_4JaQAg&ved=0CB0Q6AEwAA#v=onepa
ge&q=Praying%20and%20religion%20are%20frequently%20used%20effective%20copi
ng%20strategies&f=false
DEVELOPING A CARE PLAN
15
Assignment 2: Using Nursing Concepts and the Nursing Process
to Develop a Nursing Care Plan – Marking Guide
KEY CONTENT
MARKING GUIDE
POINTS:
5
3
1
0
Entered assessment of client findings (client name,
medical diagnosis, perception of health needs, client
goals for health, allergies, medications, dietary
considerations, client assessment, health
assessment).
Excellent
Satisfactory
Minimal
None
Entered assessment of environment findings
(Spiritual, Developmental, Sociological,
Psychological, and Determinants of Health)
Excellent
Satisfactory
Minimal
None
Entered health priorities and client strengths
Excellent
Satisfactory
Minimal
None
NURSING ASSESSMENT



/15
Comments:
NURSING CARE PLAN: NURSING DIAGNOSIS

Wrote a nursing diagnosis statement that focused
on an actual problem in reference to a client
strength or health need, related factors, and
evidence presented
Excellent
Satisfactory
Minimal
None

Wrote a nursing diagnosis statement that focused
on a potential problem in reference to a client
strength or health need, related factors, and
evidence presented
Excellent
Satisfactory
Minimal
None

Wrote a nursing diagnosis statement that focused
on a wellness diagnosis in reference to a client
wellness need, related factors, and evidence
presented
Excellent
Satisfactory
Minimal
None
/15
DEVELOPING A CARE PLAN
16
KEY CONTENT
MARKING GUIDE
POINTS:
5
3
1
0
Comments:
GOALS/EXPECTED O UTCOMES

Chose a priority diagnosis with rationale
Excellent
Satisfactory
Minimal
None

Wrote one general goal statement for the priority
diagnosis
Excellent
Satisfactory
Minimal
None

Wrote one expected outcome that included
measurable criteria by using the SMART criteria
Excellent
Satisfactory
Minimal
None
/15
Comments:
INTERVENTIONS

Nursing intervention 1. Provided support for each
intervention with evidence from the literature
Excellent
Satisfactory
Minimal
None

Nursing intervention 2. Provided support for each
intervention with evidence from the literature
Excellent
Satisfactory
Minimal
None

Nursing intervention3. Provided support for each
intervention with evidence from the literature
Excellent
Satisfactory
Minimal
None
/15
DEVELOPING A CARE PLAN
17
KEY CONTENT
MARKING GUIDE
POINTS:
5
3
1
0
Excellent
Satisfactory
Minimal
None
Comments:
EVALUATION

Identify how you plan to evaluate if goal/expected
outcomes were met or not met with rationale
/5
Comments:
SUMMARY

Described the benefits of using the nursing
process and the nursing concepts (metaparadigm
concepts and SMART criteria) in assessment and
nursing care planning
Excellent
Satisfactory
Minimal
None
/5
Comments:
TOTAL
/70
DEVELOPING A CARE PLAN
18
APA AND GRAMMAR –MARKING GUIDE
KEY CONTENT
MARKING GUIDE
POINTS:
1
0.5
0.25
0
Excellent
Satisfactory
Minimal
None
Excellent
Satisfactory
Minimal
None
TITLE PAGE

Included: header and page number; running head;
date. Remaining items centred: title of paper,
student name, college name, course and section
number, assignment name and number, instructor
name
BODY OF PAPER

Paper organized – header and page number;
introduction, body and conclusion; appropriate
margins, double-spaced throughout, indent 5 spaces
or 1 tab for new paragraphs, correct font – Times
New Roman, 12-pt. font.
REFERENCES

Citations in body of paper follow APA format
Excellent
Satisfactory
Minimal
None

References, on separate page, follow APA format
Excellent
Satisfactory
Minimal
None
Excellent
Satisfactory
Minimal
None
GRAMMAR AND SPELLING

Grammar appropriate and words spelled correctly
(< 5 errors)
TOTAL
/5
GRAND TOTAL (ALL MARKING GUIDES )
/75
Comments: