General Nursing Care

Nursing Diagnosis, Goal & its Interventions

A Guide to write Nursing Care plan
1. Anxiety- Nursing Diagnosis
Meaning: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response
(the source often nonspecific or unknown to the individual); a feeling of apprehension caused
by anticipation of danger. It is an alerting signal that warns of impending danger and enables
the individual to take measures to deal with the threat
Goal: To Reduce anxiety
Desired Outcome:
 Patient has posture, facial expressions, gestures, and activity levels that reflect decreased
distress.
 Patient identifies strategies to reduce anxiety
Planning of nursing intervention:
1. Pre monitoring: Assess the patient’s level of anxiety. (Hildegard E. Peplau described 4 levels
of anxiety: mild, moderate, severe and panic.)
2. Assess physical reactions to anxiety-(physical symptoms such as pain, nausea, weakness, or
dizziness)
3. Validate observations by asking patient, “Are you feeling anxious now?”
4. Observe how the patient uses coping techniques and defense mechanisms to cope with
anxiety-(Coping strategies may include reading, journaling, or physical activity such as
taking a walk)
5. Lessen sensory stimuli by keeping a quiet and peaceful environment; keep “threatening”
equipment out of sight-(Anxiety may intensify to a panic state with excessive conversation,
noise, and equipment around the patient)
6. Allow patient to talk about anxious feelings and examine anxiety-provoking situations if
they are identifiable.
7. Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep
breathing, positive visualization, and reassuring self-statements).
8. Inform doctor when anxiety level intensifies
9. Administer medication as per doctors order-Anti anxiety medication if advised
10. Encourage patient to listen music( if hearing music is preferred by the patient)
 11. Post monitoring: Assess the patient’s level of anxiety. Hildegard E. Peplau described 4 levels
of anxiety: mild, moderate, severe and panic
2. Aspiration, Risk for- Nursing Diagnosis
Note: Is applicable when your patient is on ryles tube feeding
Meaning: Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal
Secretion, solids, or fluids into tracheobronchial passages.
Goal: To reduce the risk of Aspiration
Desired Outcome:
 Patient is free of signs of aspiration and the risk of aspiration is decreased.
 Patient expectorates clear secretions and is free of aspiration.
 Patient maintains a patent airway with normal breath sounds.
 Patient swallows and digests oral, nasogastric, or gastric feeding without aspiration.
Planning of nursing intervention:
 Assess level of consciousness.
 Pre Monitoring: Monitor respiratory rate, depth, and effort. Note any signs of aspiration
such as dyspnea, cough, cyanosis, wheezing, or fever.
Evaluate swallowing ability by assessing for the following:
 Coughing, choking, throat clearing, gurgling or “wet” voice during or after swallowing
 Residual food in mouth after eating
 Regurgitation of food or fluid through the nares
 Assess for presence of nausea or vomiting.
 Auscultate bowel sounds to assess for gastrointestinal motility.
In patients with NG tube
 Check placement before feeding, using tube markings, x-ray study (most accurate), pH of
gastric fluid, and color of aspirate
 Check residuals before feeding,. Hold feedings if amount of residuals is large, and notify the
physician.
 Keep suctioning articles readily available when feeding high-risk patients. If aspiration does
occur, suction immediately.
 Keep head of bed elevated when feeding and for at least a half hour afterward.
 Allow the patient to chew thoroughly and eat slowly during meals.
 During enteral feedings, position patient with head of bed elevated 30 to 40 degrees; maintain
for 30 to 45 minutes after feeding.
  Elevate the head of bed to 30 to 45 degrees while feeding the patient and for 30 to 45 minutes
afterward if feeding is intermittent. Turn off the feeding before lowering the head of bed.
Patients with continuous feedings should be in an upright position.
 Post Monitoring: Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as
dyspnea, cough, cyanosis, wheezing, or fever.
3. Blood Glucose Level, Risk for Imbalanced- Nursing Diagnosis
Note: DM patient /if your patient is taking insulin in any form/when patients blood glucose is monitored
upon doctors instruction
Meaning: Risk for Unstable Blood Glucose Level: Risk for variation of blood glucose/sugar levels from
the normal range.
Hyperglycemia or elevated blood glucose levels may occur in a variety of clinical situations.
Diabetes mellitus is the most common disorder associated with elevated blood glucose levels. Certain
drugs have hyperglycemia as a side effect.
Hypoglycemia, otherwise, occurs most often as the result of excess insulin administration in the
person with diabetes mellitus. It may also occur to a person who has excessive alcohol intake, prolonged
fasting and starvation states, adrenal insufficiency, and eating disorders such as anorexia nervosa.
Goal: To eliminate the risk of Imbalanced Blood Glucose Level
Desired Outcome: Patient has a blood glucose reading of less than 180 mg/dL; fasting blood glucose
levels of less than <140 mg/dL;
Planning of nursing intervention:
 Pre-Monitoring: Assess for signs of hyperglycemia- increased thirst (polydipsia), hunger
(polyphagia), and increased urination (polyuria)
 Assess for signs of hypoglycemia- experience tachycardia, diaphoresis, tremors, dizziness,
headache, fatigue, hunger, and visual changes.
 Monitor blood glucose levels as per doctors instruction(Fasting, PPBS, RBS)
 Assess for anxiety, tremors, and slurring of speech.
 Assess eating patterns.
 Refer to a registered dietitian for individualized diet instruction
 Administer insulin as per doctor instruction
 Inform doctor when BP goes more than 160 mm Hg (systolic) - Hypertension is commonly
associated with diabetes.
 Educate the patient about the importance of following a prescribed meal plan.
 Educate the patient about the proper ways of taking prescribed medications.
 Discuss the importance of balance exercise with food intake.
 Teach the patient on measuring capillary blood glucose.
 Instruct patient to carry medical alert information.
 Refer the patient to an exercise physiologist, physical therapist, for specific exercise instructions.
 Assess for signs of hyperglycemia- increased thirst (polydipsia), hunger (polyphagia), and
increased urination (polyuria)
 Post Monitoring: Assess for signs of hypoglycemia- experience tachycardia, diaphoresis,
tremors, dizziness, headache, fatigue, hunger, and visual changes.
4. Comfort, Impaired- Nursing Diagnosis
Goal: To increase the comfort of the patient
Planning of nursing intervention:
 Pre Monitoring- Monitor Vital Signs
 Promote comfort by making sure patient is positioned properly.
 Provide Comfort devices to keep the patient comfortable
 Administer (pain) medications as per Doctor’s order
 Encourage deep breathing exercises
 Diversional activites such as reading a book, watching TV or playing board games
 Energy conservation techniques such as resting whenever possible
 Post Monitoring - Monitor Vital Signs
5. Constipation- Nursing Diagnosis
Meaning: Decrease in normal frequency of defecation accompanied by difficult or incomplete
passage of stool and/or passage of excessively hard, dry stool.
Goal: To prevent Constipation
Desired Outcome:
o Patient maintains passage of soft, formed stool at a frequency perceived as “normal” by
the patient.
o Patient states relief from discomfort of constipation
o Planning of nursing intervention:
Planning of nursing intervention:
 Pre Monitoring- Check on the usual pattern of elimination, including frequency and
consistency of stool.
 Evaluate for fear of pain with defecation
 Inform doctor the severity of the problem
  Encourage the patient to take in fluid 2000 to 3000 mL/day, (if not contraindicated
medically).
 Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole
grains) per day - (which should be advised based on the consultation of the Dietitian )

 Close the bathroom door or pull curtains around the bed- (This position best uses gravity
and allows for effective Valsalva maneuver.Privacy is very important because it helps the
patient feel comfortable for defecation).
 Discuss with a dietitian about dietary sources of fiber
 Explain to the patient and caregiver the importance of the following:
o A balanced diet that comprises adequate fiber, fresh fruits, vegetables, and grains
o Sufficient fluid intake (eight glasses per day or 2000 to 3000 mL/day).If not
contraindicated
o A regular period for elimination and an adequate time for defection
o Regular exercise and activity
o Privacy for defecation
 Administer doctor’s prescription(Stool softeners, Suppositories, Oil retention enema )
 Post Monitoring: Check on the usual pattern of elimination, including frequency and
consistency of stool.
6. Diarrhea- Nursing Diagnosis
Meaning: Passage of loose, unformed stools.
Goal: To eliminate or reduce the episodes of diarrhea
Desired Outcome:
o Patient reports less diarrhea within 36 hours.
o Patient defecates formed, soft stool
o Patient states relief from cramping and less or no diarrhea
o Patient has negative stool cultures.
Planning of nursing intervention:
o Pre Monitoring - Assess for abdominal discomfort, pain, cramping, frequency,
urgency, loose or liquid stools, and hyperactive bowel sensations.
o Inform doctor on the severity of the problem
o Pre Monitoring -Assess hydration status, including:

o Input and output

o Moisture of mucous membranes
 o Skin turgor
o Weigh patient daily and note decreased weight.
o Administer medication as per doctors order- antidiarrheal drugs
o Refer the patient to the dietitian for an advice upon diet
o Record number and consistency of stools per day;
o Evaluate dehydration by observing skin turgor over sternum and inspecting for
longitudinal furrows of the tongue. (Watch for excessive thirst, fever, dizziness,
lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and
symptoms of shock).
o Encourage fluids 1.5 to 2 L/24 hr plus 200 mL for each loose stool in adults unless
contraindicated; consider nutritional support.
o Monitor and record intake and output; note oliguria and dark, concentrated urine.
Measure specific gravity of urine if possible-(Dark, concentrated urine, along with
a high specific gravity of urine, is an indication of deficient fluid volume.)
o Provide perianal care after each bowel movement).
o Administer tube feeding at room temperature- (Extremes of temperature can
stimulate peristalsis).
o Educate the patient or caregiver about the following dietary measures to control
diarrhea:
o Avoid spicy, fatty foods, alcohol, and caffeine.
o Broil, bake, or boil foods; avoid frying.
o Discuss the importance of fluid replacement during diarrheal episodes.
o Post Monitoring - Assess for abdominal discomfort, pain, cramping, frequency,
urgency, loose or liquid stools, and hyperactive bowel sensations
7. Falls ,Risk for- Nursing Diagnosis
Meaning: Risk for Falls: Increased susceptibility to falling that may cause physical harm.
Goal: To prevent falls
Desired Outcome:
o Patient will relate the intent to use safety measures to prevent falls.
o Patient will demonstrate selective prevention measures.
o Patient and caregiver will implement strategies to increase safety and prevent falls in
the home.
Planning of nursing intervention:
 Note: Could be used when your patient comes under vulnerable category
 Pre Monitoring - Asses the vulnerability of the patient using CAPS Scoring and by the
vulnerable list
o Assess for circumstances associated to increase the level of fall risk upon admission
o Pre Monitoring - Asses the vulnerability of the patient using CAPS Scoring and by the
vulnerable list
o Inform doctor the vulnerability of the patient
o Safety first sticker to be placed at the head end of the patient
o Minimize waiting times in OPD & diagnostics
o Provide prompt attention, put safety first sticker at bed side.
o Vulnerable patients shall not be left alone at any given time.
o Appropriate Fall risk assessment shall be done
o Accompany the patient to the wash room
o Female patients and children of both genders will be attended for their physical
interventions such as bathing and toilet by a female attendant / ward nurse.
o Patient should not be left unattended.
o Call bell should be at the reach of patient
o Regular monitoring will be ensured by supervisory staff to ensure the safety and
security of vulnerable patients.
o Avoid slippery floors
o Seat belts are used while transporting the patients by stretcher or wheel chairs.
o Side rails shall be put up beside the bed throughout the hospital stay
o Post Monitoring - Asses the vulnerability of the patient using CAPS Scoring and by the
vulnerable list
8. Fatigue- Nursing Diagnosis
Meaning: Fatigue: An overwhelming sustained sense of exhaustion and decreased capacity for
physical and mental work at usual level.
Goal: To reduce fatigue
Desired Outcome:
o Patient demonstrates energy saving techniques to help decrease fatigue.
o Patient explains energy conservation plan to offset fatigue
Planning of nursing intervention:
 o Pre Monitoring- Evaluate the patient’s description of fatigue: severity, changes in
severity over time, aggregating factors or alleviating factors.
o Determine possible causes of fatigue, such as:
 Last physical illness
 Pain
 Emotional stress
 Depression
 Side effects of medication
 Anemia
 Sleep disorders
o Assess the patient’s ability to perform ADLs
o Assess the patient’s nutritional ingestion for adequate energy sources and metabolic
demands
o Promote sufficient nutritional intake.
o Offer diversional activities that are soothing.
o Aid the patient develop habits to promote effective rest/sleep patterns.
o Encourage Patient to do exercise –(Plan for support form physiotherapist )
9. Fear - Nursing Diagnosis
Meaning:
Goal: To reduce the fear of the patient
Desired Outcome: client will experience a reduction in fear and anxiety as evidenced by:
o verbalization of feeling less anxious
o usual sleep pattern
o relaxed facial expression and body movements
o stable vital signs
o usual perceptual ability and interactions with others
Planning of nursing intervention:
 Pre Monitoring - Assess client for signs and symptoms of fear and anxiety (e.g.
verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness,
diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors).
 orient client to environment, equipment, and routines;
 introduce client to staff who will be participating in care;
 assure client that staff members are nearby; respond to call signal as soon as possible
  Keep door and curtains open as much as possible to reduce feeling of confinement
 maintain a calm, supportive, confident manner when interacting with client
 encourage verbalization of fear and anxiety; provide feedback
 reinforce physician's explanations and clarify misconceptions client has about the
diagnosis, treatment plan, and prognosis
 explain all diagnostic tests
 provide a calm, restful environment
 instruct client in relaxation techniques and encourage participation in diversional
activities
 assist client to identify specific stressors and ways to cope with them
 Administer prescribed anti-anxiety agents if indicated.
 Post Monitoring - Assess client for signs and symptoms of fear and anxiety (e.g.
verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness,
diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors).
10. Hyperthermia- Nursing Diagnosis
Meaning: Hyperthermia: Body temperature elevated above normal range.
Goal: To reduce patients body temperature to normal
Desired Outcome:
 Patient maintains body temperature below 39° C (102.2° F).
 Patient maintains BP and HR within normal limits.
Planning of nursing intervention:
 Pre Monitoring - Monitor the patient’s body temperature, HR, BP,
 Monitor fluid intake and urine output- Fluid resuscitation may be required to correct
dehydration. The patient who is significantly dehydrated is no longer able to sweat,
which is necessary for evaporative cooling.
 Review serum electrolytes, especially serum sodium – (Sodium losses occur with profuse
sweating and accidental hyperthermia).
 Provide tapid sponging
 Inform doctor if temperature goes above ______degree
 Adjust and monitor environmental factors like room temperature and bed linens as
indicated.
 Administer medication as per doctor’s order- (antipyretic medications as prescribed).
  Ready oxygen therapy for extreme cases-( Hyperthermia increases the metabolic
demand for oxygen).
 Encourage ample fluid intake by mouth if not contra indicated and as per doctors
instruction
 Raise the side rails at all times-(This is to ensure patient’s safety even without the
presence of seizure activity)
 Educate patient and family members about the signs and symptoms of hyperthermia
and help in identifying factors related to occurrence of fever; discuss importance of
increased fluid intake to avoid dehydration.
 Post Monitoring- Monitor the patient’s body temperature, HR, BP
11. Hypothermia- Nursing Diagnosis
Meaning: Hyperthermia: Body temperature less than normal range.
Goal: To increase patients body temperature to normal
Desired Outcome: To maintain patients body temperature within normal limits(_______)
Planning of nursing intervention:
 Pre monitoring: Asses patients temperature as a baseline data
 Provide warming with bear hugger warming blanket system
 Inform doctor if temperature goes less than 95 degree not beck normal in an hour
 Asses patients HR and BP
 The nurse will assess patient’s room temperature every 2 hours and will keep patient’s
room temperature closer to 72 degrees.
 Post monitoring - Asses patients temperature at the end of the shift
12. Hypothermia, Risk for- Nursing Diagnosis
13. Hypothermia, Risk for Perioperative - Nursing Diagnosis
14. Risk for Infection- Nursing Diagnosis
Goal: patient to remain infection free
Planning of nursing intervention:
 Pre Monitoring - Assess temperature every ___ hours- (Temperature of up to 38° C (100.4° F)
for 48 hours after surgery is related to surgical stress; after 48 hours, temp. greater than 37.7°
C (99.8° F) suggests infection.)
 Assess for presence, existence of, and history of risk factors-( such as indwelling catheters (e.g.
foley); open wounds and abrasion; wound drainage tubes (T-tubes, Jackson-Pratt, Penrose);
venous or arterial access devices; ETT or tracheostomy tubes; orthopaedic fixator pins).
 Pre Monitoring- Inspect and record signs of erythema, induration, foul smelling drainage, from
or around wound, skin, invasive line, mouth/throat, exit sites of tubes, drains or catheters or
other site every __ hours
 Assess nutritional status, including weight, history of weight loss and serum albumin. Patients
with poor nutritional status may me anergic or unable to muster a cellular immune response to
pathogens and are therefore more susceptible to infection.
 Assess immunization status. Older patients may not have completed immunizations and
therefore may not have sufficient acquired immunocompetence.
 Maintain asepsis for (dressing changes and wound care, catheter care and handling, and
peripheral IV and central venous access management)
 Follow hand hygine technique strictly
 Limit visitors
 Encourage high protein/high carbohydrate foods/fluids( as per the direction of the dietitian)
 Encourage fluid intake of 2,000 to 3,000 mL of water per day (unless contraindicated)- (Fluids
promote diluted urine and frequent emptying of the bladder; reducing stasis of urine, in turn,
reduces risk of bladder infection or urinary tract infection).
 Encourage coughing and deep breathing; consider use of incentive spirometer. (These measures
reduce stasis of secretions in the lungs and bronchial tree)
 Inform doctor if there is any signs /evidence of infection seen/found
 Administer medication as per doctors instruction
 Place the patient in protective isolation/protective environment
 Teach the patient the importance of avoiding contact with those who have infections or colds.
Teach family members and caregivers about protecting susceptible patients from themselves
and others with infections and colds.
 Teach the patient, family, and caregivers the purpose and proper technique for maintaining
isolation. Knowledge about isolation can help patients and family members cooperate with
specific precautions
 Teach the patient to take antibiotics as prescribed
 Instruct the patient to take the full course of antibiotics even if symptoms improve or disappear
 Post Monitoring - Assess temperature at the end of the shift
 Post Monitoring- Inspect and record signs of erythema, induration, foul smelling drainage, from
or around wound, skin, invasive line, mouth/throat, exit sites of tubes, drains or catheters or
other site every __ hours
 15. Insomnia- Nursing Diagnosis
Goal: To resume normal sleep pattern for the patient
Desired outcome:
Planning of nursing intervention:
16. Knowledge ,Deficient- Nursing Diagnosis
Note: Could be used during Pre-operative phase and post-Operative phase
Goal: To improve patients knowledge to reduce fear and anxiety
Planning of nursing Intervention:
 Asses the knowledge level of the patient
 Asses the understanding level of the patient
 Involve doctor to explain the necessary information
 Educate them the positive outcome of the treatment
 Explain the procedure before doing
 Encourage patient to escalate doubts related to disease condition etc.
17. Mobility, Impaired Physical- Nursing Diagnosis
Meaning: Impaired Physical Mobility: Limitation in independent, purposeful physical movement
of the body or of one or more extremities.
Goal: To improve physical mobility
Desired Outcome: Patient performs physical activity independently or within limits of disease.
Planning of nursing intervention:
 Pre Monitoring - Check for functional level of mobility.(Excellent, good, fair, poor)
 Pre Monitoring- Evaluate patient’s ability to perform Activities of Daily Living efficiently
and safely on a daily basis.
 0 – Completely independent
 1 – Requires use of equipment or device
 2 – Requires help from another person for assistance, supervision, or
teaching
 3 – Requires help from another person and equipment or device
 4 – Is dependent, does not participate in activity
 Monitor nutritional needs as they relate to immobility.(Involve dietitian)
 Evaluate the need for assistive devices.
 Assess the safety of the environment.
  Note for progressing thrombophlebitis (e.g., calf pain, Homan’s sign, redness, localized
swelling, a rise in temperature).
 Check for skin integrity for signs of redness and tissue ischemia (especially over ears,
shoulders, elbows, sacrum, hips, heels, ankles, and toes).
 Note elimination status (e.g., usual pattern, present patterns, signs of constipation).
 Assist patient for muscle exercises as able or when allowed out of bed (with the assistance of
physiotherapist)
 Present a safe environment: bed rails up, bed in down position, important items close by.
 Provide nimbus bed as necessary.
 Promote and facilitate early ambulation when possible. Aid with each initial change:
dangling legs, sitting in chair, ambulation
 Identify the use of mobility devices, such as the following: trapeze, crutches, or walkers.
 Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage
independent activity as able and safe.
 Give positive reinforcement during activity. Patients may be unwilling to move or initiate
new activity because of fear of falling.
 Inform doctor if patient displays any improvement in his physical mobility
 Administer medication as per doctors order
 Help patient develop sitting balance and standing balance with the assistance of
physiotherapist
 Turn and position the patient every 2 hours or as needed.
 Encourage coughing and deep-breathing exercises.
 Explain to the patient the need to call for help, such as call bell
 Post Monitoring - Check for functional level of mobility.(Excellent, good, fair, poor)
 Post Monitoring- Evaluate patient’s ability to perform Activities of Daily Living efficiently
and safely on a daily basis.
 0 – Completely independent
 1 – Requires use of equipment or device
 2 – Requires help from another person for assistance, supervision, or
teaching
 3 – Requires help from another person and equipment or device
 4 – Is dependent, does not participate in activity
18. Pain, Acute- Nursing Diagnosis
 Goal: To Reduce pain
Desired outcome: Patient describes satisfactory pain control on a rating scale of 0 to 10.
Planning of nursing intervention:
 Pre Monitoring-Asses pain using pain rating scale .
 Pre Monitoring- Assess pain characteristics:

o Quality (e.g., burning, sharp, shooting)

o Severity (scale of 0 or no pain to 10 or most severe pain)
o Location (anatomical description)
o Onset (gradual or sudden)
o Duration (how long; intermittent or continuous)
o Precipitating or relieving factors
 Assess for signs and symptoms relating to pain.
 Tingling in the extremities, numbness, a metallic taste in the mouth (if patient is on epidural
analgesia)
 Potential epidural analgesia complications such as extreme sedation, respiratory distress,
urinary retention, or catheter migration
 Evaluate the patient’s response to pain and management strategies
 Acknowledge reports of pain immediately & Inform doctor if necessary
 Provide rest periods to promote relief, sleep, and relaxation.
 Administer medication as per doctors order-Analgesics
 Provide non pharmacological management
o Imagery
o Distraction techniques
o Relaxation exercises, biofeedback, breathing exercises, music therapy
 Provide Hot or cold compress
 Inform doctor when interventions found unsuccessful and ineffective.
 Label all tubing (e.g., epidural catheter, IV tubing to epidural catheter) clearly to prevent the
accidental administration of unseemly fluids or drugs into the epidural space.
 Post Monitoring- Asses pain using pain rating scale .
19. Pain, Chronic- Nursing Diagnosis
20. Pressure ulcer, Risk for- Nursing Diagnosis
21. Impaired Skin Integrity- Nursing Diagnosis
Goal: To maintain skin integrity of the patient
 Desired Outcome: Client will experience healing of pressure ulcers and experiences pressure
reduction
Planning of nursing intervention:
o Pre Monitoring- Assess the specific risk factors for pressure ulcer:
o Assess the skin on admission and daily for an increasing number of risk factors
o Assess for fecal and urinary incontinence.
o Assess client’s ability to move (shift weight while sitting, turn over in bed, move from the
bed to a chair).
o Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the client’s
skin.
o Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner
and outer malleolus, inner and outer knees, back of the head).
o Use an objective tool for pressure ulcer risk assessment:

 Braden scale.
o Assess and stage the pressure ulcers.
o Determine the condition of the wound or wound bed.
 Presence of necrotic tissue.
 Color-( The color of tissue is an indication of tissue viability and
oxygenation. White, gray, or yellow eschar may be present in stage II and III
ulcers. Eschar may be black in stage IV ulcers.)
 Odor- (Odor may arise from infection present in the wound);.
 Viability of bone, joints, or muscle-( In stage IV pressure ulcers, these may
be apparent at the base of the ulcer)
 Measure the size of the ulcer,
o Apply dressing upon the wound if indicated/upon doctors instruction
o Inform doctor the presence of pressure ulcer & the condition of the pressure ulcer
o Provide second hourly position changing
o check for the need for nimbus bed
o Provide back care to maintain skin integrity
Note: When a patient is confined to bed
22. Self- Care Deficit, Bathing - Nursing Diagnosis
Note: Could be used, when a patient is assisted with bathing
23. Self-Care Deficit, Feeding- Nursing Diagnosis
Note: Could be used for patients to whom feeding been provided through ryles tube
24. Self-Care Deficit, Toileting- Nursing Diagnosis
Note: If a patient required assistance to meet their toileting need
25. Sleep Pattern, Disturbed- Nursing Diagnosis
26. Standing ,Impaired - Nursing Diagnosis
27. Verbal Communication ,Impaired - Nursing Diagnosis

Evaluation :
1. When to do Evaluation?
Evaluation should be done at the end of every shift
2. How many types of Evaluations are there and which of those are important?
There are three types of evaluation
Following Evaluations are important:
 On-Going evaluation
 Terminal Evaluation
3. What is the name of the evaluation which is done at the end of the shift?
 Terminal Evaluation
4. How to write terminal evaluation
If the identified problem is solved then following would be documented in the evaluation
column:
Goal met, Client has progressed and achieved desired outcome & Goal
If the identified problem persist but shows improvement following would be documented in the
evaluation column:
Goal partially met, client will require continued intervention and condition is
improving
If there is no improvement then following would be documented in the evaluation column:
Goal not met. Client’s condition still indicates the problem, Client requires continued
therapy with possibly new interventions

Note: Under planning of nursing intervention. Italic sentences are not actual planning’s but are
rationalization/ additional information/instructions to the respective planning.