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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: