NURSING CARE PLAN (LABORATORY LECTURE)

o Physical Examination
OUTLINE ▪ Cephalocaudal
I Assessment ▪ ROS
A Types of Data ▪ Partial PE
B Methods of Data Collection
II Diagnosis
▪ IPPA
A Nursing Diagnosis ▪ VS TPR BP VAS(Pain)
B Data Analysis ▪ Provide comfort and privacy.
C Formulation of Nursing Diagnosis ▪ Uses the senses and skills.
D Types of Nursing Diagnosis o Medical Record Review
E Writing Nursing Diagnosis ▪ Patient chart and previous chart.
III Planning ▪ History of past illness, family illness, present
A Goals illness, etc.
B Setting Priorities
C Establishing Outcomes
▪ Forms – MIAD
i Goals • Uses data collection format (MIAD).
D Discharge Outcomes • Uses some theories as basis/guide.
IV Implementation o Maslow’s
A Intervention o Virginia Henderson
i Types of Intervention o Gordon’s Functional Health Patterns
B Implementation o Orem
V Evaluation
VI Nursing Care Plan
o Roy
A NCP Format • Consider Culture
B NCP vs. NCM
C Documentation DIAGNOSIS
i PDAR • Second step in the nursing process.
ii FDAR
• Analyzes the data gathered.
VII Patient Teaching
• Identifies problem areas for the patient.
• Diagnosing vs. Nursing Diagnosis
ASSESSMENT • Diagnosing = Data Analysis + Problem Identification
• Judgment and conclusion
• Initial step – basis for care plan.
• Data Collection
o Collects and analyzes data about the patient. NURSING DIAGNOSIS
• Validates, organizes, and records data. • Specific result of diagnosing and problem statement.
• Initial Assessment • The clinical judgment about patient’s response to actual or
o Basis for patient care plan. potential health conditions or needs (AA).
• Later Assessment • Provide basis for determination of a plan of care to achieve
o Revision (evaluation) expected outcomes (ANA).
• Basic yet most complex nursing skill.
𝐃𝐢𝐚𝐠𝐧𝐨𝐬𝐢𝐬 = 𝐷𝑎𝑡𝑎 𝐴𝑛𝑎𝑙𝑦𝑠𝑖𝑠 + 𝑃𝑟𝑜𝑏𝑙𝑒𝑚 𝐼𝐷
+ 𝐹𝑜𝑟𝑚𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑁𝑢𝑟𝑠𝑖𝑛𝑔 𝐷𝑖𝑎𝑔𝑛𝑜𝑠𝑖𝑠
TYPES OF DATA
1. Subjective Data (Symptom)
- Patient feelings (Verbalization)
DATA ANALYSIS
- Pediatric (NB) • Check for completeness of data.
- Stroke • Cultural aspects of data,
2. Objective Data (Signs) • Check consistencies and ambiguity.
- TPR BP, O2 Sat, Labs • Data evaluated for comprehensiveness.

METHODS OF DATA COLLECTION FORMULATION OF NURSING DIAGNOSIS

• Methods of Data Collection
o Observation
▪ High-level nursing skill.
▪ Observe and recall
▪ E.g., a student nurse giving bed bath.
o Interview
▪ Structured form of communication.
▪ Has the ability to ask questions and listen.
▪ Make the patient comfortable as possible.
▪ Nursing admission assessment or nursing history.
▪ To get actual or potential problem.
▪ Review patient’s past health history and lifestyle.
▪ Can use open ended questions.
• Use NANDA
o North American Nursing Diagnosis Association
• Principal organization for defining, distribution, and
integration of standardized nursing diagnoses worldwide.
• Check list
• Nursing Diagnosis
o Refers to one of many diagnoses in the classification
system established and approved by NANDA.
o Based upon the response of the patient to medical
condition.
o Matters that hold a distinct and precise action that is
associated with what nurses have autonomy to take
action about with a specific disease or condition.

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 TRANS: Nursing Care Plan (Laboratory Lecture)

• Medical Diagnosis • Set priorities.

o Made by the physician or advance health care o Based on theories.
practitioner that deals more with disease, medical • Set goals and objectives.
condition, or pathological state only a practitioner can o Short-Term Goal
treat. o Long-Term Goal
o Through experience and know-how, the specific and • SMART
precise clinical entity that might be the possible cause o Specific
of the illness will then be undertaken by the doctor; o Measurable
therefore, providing the proper mediation that would o Attainable
cure the illness. o Realistic
o Time-Bound
Table 2.3.1 Diagnosis Examples
NURSING DX MEDICAL DX GOALS
Ineffective airway clearance Pneumonia • Client Goal/Outcome Criteria/Outcome Identification/
Impaired gas exchange Asthma, ARDS, COPD Nursing Goals
Disturbed body image Amputation • Statement/s that describe a measurable behavior of the
Decreased cardiac output Myocardial infarction client or family denoting a favorable status
Decreased fluid volume Hemorrhage (changed/maintained) after delivery of nursing care.
• Serves as standards for measuring care plan’s
TYPES OF NURSING DIAGNOSIS effectiveness.
1. Actual Diagnosis • Subject for evaluation or reevaluation.
- Problem existing at present.
2. Risk Nursing Diagnosis 𝐎𝐮𝐭𝐜𝐨𝐦𝐞 𝐄𝐯𝐚𝐥𝐮𝐚𝐭𝐢𝐨𝐧
- Clinical judgment that is more vulnerable to = 𝑆𝑒𝑡𝑡𝑖𝑛𝑔 𝑃𝑟𝑖𝑜𝑟𝑖𝑡𝑖𝑒𝑠
develop. + 𝐸𝑠𝑡𝑎𝑏𝑙𝑖𝑠ℎ𝑖𝑛𝑔 𝑂𝑢𝑡𝑐𝑜𝑚𝑒𝑠
3. Possible Nursing Diagnosis
- Incomplete problem statement. SETTING PRIORITIES
- Uncertain but could happen. • Consider Maslow’s Hierarchy of Needs
• Focus on the problem the patient feels are important.
WRITING NURSING DIAGNOSIS o Does not interfere with the medical treatment.
• Actual Nursing Diagnosis o Offers opportunity to set their priorities.
o Nursing Diagnosis = Patient Problem + Causes • Consider the patient’s culture, values, and beliefs.
Known • Consider the potential problems when setting priorities.
▪ Impaired skin integrity r/t immobility. • Consider costs, resources available, personnel, and time
▪ Imbalanced nutrition less than body requirements needed to plan.
r/t persistent vomiting. • Consider state law, hospital policy, and outcome criteria.
o Nursing Diagnosis = Problem + Etiology + S/S
▪ Impaired skin integrity r/t physical immobilization,
redness, and lesion at the elbows and coccyx
area.

• Risk Nursing Diagnosis

o Nursing Diagnosis = Problem + Risk Factors
▪ Risk for impaired skin integrity r/t physical
immobilization.

PLANNING
• Determine beforehand the strategies or course of action to ESTABLISHING OUTCOMES
be taken before implementation of nursing care. • “Measurable, expected, client-focused goal” to be achieved
• To effectively involve patient, family, and significant others. at some specified time in the future.
• Purpose is to identify the client’s goals and appropriate • Patient-outcome desired result
nursing intervention. • Gives guidance in the selection of nursing interventions.
• Provide “blue print” to direct charting. • Constant future target to remind why certain activities are
• Communicate to the nursing staff what to teach, what to done.
observe and what to implement. • Gives a standard to compare the patient’s status hourly,
• Provide goals (outcome criteria) for reviewing and daily, weekly, monthly, and/or yearly.
evaluating critical care. • Gives a sense of where patient started from and where the
• Directs specific interventions for the client, family, and other nurse hopes to end.
nursing staff to implement. • Helps to motivate the nurse, the patient, and the family to
continue their efforts,

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 TRANS: Nursing Care Plan (Laboratory Lecture)

• When outcomes are achieved, it provides everyone a • Carry out planned nursing interventions to help client attain
reward of success. goals.
• Components of Outcome Statement • Requirements for Implementation
o Knowledge
𝐎𝐮𝐭𝐜𝐨𝐦𝐞 𝐒𝐭𝐚𝐭𝐞𝐦𝐞𝐧𝐭 o Technical Skills (Nursing Skills/Procedure)
= 𝑃𝑎𝑡𝑖𝑒𝑛𝑡 𝐵𝑒ℎ𝑎𝑣𝑖𝑜𝑟 ▪ Based on SOP of the hospital.
+ 𝐶𝑟𝑖𝑡𝑒𝑟𝑖𝑎 𝑜𝑓 𝑃𝑒𝑟𝑓𝑜𝑟𝑎𝑛𝑐𝑒 + 𝐶𝑜𝑛𝑑𝑖𝑡𝑖𝑜𝑛𝑠 o Commutation Skills
+ 𝑇𝑖𝑚𝑒 𝐹𝑟𝑎𝑚𝑒 o Therapeutic Communication
▪ Use of the self.
GOALS
• Short-Term Goals 𝐈𝐦𝐩𝐥𝐞𝐦𝐞𝐧𝐭𝐢𝐧𝐠 = 𝑉𝑎𝑙𝑖𝑑𝑎𝑡𝑖𝑛𝑔 𝐶𝑎𝑟𝑒 𝑃𝑙𝑎𝑛 + 𝐴𝑐𝑡𝑖𝑜𝑛
o Intermediate outcomes + 𝐷𝑜𝑐𝑢𝑚𝑒𝑛𝑡𝑖𝑛𝑔 𝐶𝑎𝑟𝑒 𝑃𝑙𝑎𝑛
o Interventions achieved in hours, 8 hour-shift, or a daily + 𝐶𝑜𝑛𝑡𝑖𝑛𝑢𝑖𝑛 𝐷𝑎𝑡𝑎 𝐶𝑜𝑙𝑙𝑒𝑐𝑡𝑖𝑜𝑛
basis.
o Case to case basis. EVALUATION
o Examples • Assessing client’s response and then comparing the
▪ At the end of the shift, the patient will be able to response to predetermined standards or outcome criteria.
void 250 mL of urine or more. • Evaluation vs. Expected Outcome
▪ Within 8 hours of duty, the patient will be able to o Evaluation
drink at least 500 mL of fluids. ▪ Goal met
▪ Within 1-2 hours of nursing intervention, the ▪ Partially met
patient’s temperature will lower down to normal ▪ Not met
(36.5-37.5 C) o Expected Outcome
• Long-Term Goals ▪ To again weight appropriate for age.
o Long-term of final outcomes ▪ To have adequate blood components after blood
o Gives direction for nursing care over time. transfusion.
o Case to case basis. ▪ Patient will be controlled at acceptable level.
o Achievable within days, weeks, months, or years.
o Consider the prognosis of the patient’s health 𝐄𝐯𝐚𝐥𝐮𝐚𝐭𝐢𝐧𝐠
problems, resources available, strengths, and = 𝐷𝑜𝑐𝑢𝑚𝑒𝑛𝑡𝑖𝑛𝑔 𝑅𝑒𝑠𝑝𝑜𝑛𝑠𝑒𝑠 𝑡𝑜 𝐼𝑛𝑡𝑒𝑟𝑣𝑒𝑛𝑡𝑖𝑜𝑛𝑠
weaknesses of patient, family, and staff. + 𝐸𝑣𝑎𝑙𝑢𝑎𝑡𝑖𝑛𝑔 𝐸𝑓𝑓𝑒𝑐𝑡𝑖𝑣𝑒𝑛𝑒𝑠𝑠 𝑜𝑓 𝐼𝑛𝑡𝑒𝑟𝑣𝑒𝑛𝑡𝑖𝑜𝑛𝑠
o Examples + 𝐸𝑣𝑎𝑙𝑢𝑎𝑡𝑖𝑛𝑔 𝑂𝑢𝑡𝑐𝑜𝑚𝑒 𝐴𝑐ℎ𝑖𝑒𝑣𝑒𝑚𝑒𝑛𝑡 + 𝑅𝑒𝑣𝑖𝑒𝑤 𝑁𝐶𝑃
▪ After 1-2 days of nursing intervention, the atient
will be able to defecate. NURSING CARE PLAN
▪ Within 3-5 days, the patient will be able to
establish normal voiding patters. NCP FORMAT
▪ Patient will e able to clean colostomy 1 month after Asses Nursin Plan Imple Ration Evalua
surgery. sment g Dx mentat ale tion
ion
DISCHARGE OUTCOMES Subject STG Interve
• Seen at the end of the clinical pathway. ive ntion:
• Patient MGH and continue recovering. Cues LTG Indepe
ndent
IMPLEMENTATION Objecti
ve Depen
INTERVENTIONS Cues dent
• Nursing Actions/Nursing Strategies/Nursing Treatment
Plan Collabo
• Specific activities, nurse plans, and implementations to help rative
the patient achieve outcome.
• Nursing orders – doctor’s order NCP VS. NCM
• Can use problem solving approach – selects activities to do • Nursing Care Plan
– outcome. o The blueprint, which usually is want a nurse would want
• Communicated to other nurses to do to the patient.
o Future tense implementation.
TYPES OF INTERVENTION o Evaluation – expected outcome
• Nursing Care Management
4. Independent Interventions
o You have already done these procedures to the
- Nurse initiated and ordered interventions.
patient.
- Solely in the range of professional nursing.
o Past tense implementation.
- Samples include give TSB and health teaching.
o Evaluation – evaluation
5. Dependent Interventions
- Physician initiated and ordered interventions.
- Doctor’s order. DOCUMENTATION
6. Collaborative Interventions • PDAR/FDAR
- With the help of allied health care workers. o Problem Data Action Response
o Focus Data Action Response
IMPLEMENTATION • Problem Data Action Response
• Putting nurse care plan into action. • Focus DAR

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 TRANS: Nursing Care Plan (Laboratory Lecture)

PDAR
• Problem
o Fever (Hyperthermia)
• Data
o Temperature: 39 C
o Skin is warm to touch, flushed skin.
• Action
o Referred to AMD or AMD notified.
o TSB done.
o Paracetamol tablet was given.
o Temperature rechecked after an hour.
• Response
o Temperature was lowered to 37.7 C after an hour.

FDAR
• Focus
o To lower down the temperature.
• Data
o Temperature: 39 C
o Skin is warm to touch, flushed skin.
• Action
o Referred to AMD or AMD notified.
o TSB done.
o Paracetamol tablet was given.
o Temperature rechecked after an hour.
• Response
o Temperature was lowered to 37.7 C after an hour.

PATIENT TEACHING
• Discharge instructions: METHODS
o Medication
o Environment
o Treatment
o Health Teachings
o Outpatient
o Diet
o Spiritual, Sexual, Social (as appropriate)

DAHNE XYRUS L. CORPORAL | ST. LUKE’S COLLEGE OF NURSING | 2NU03 4