ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION

DIAGNOSIS AND CORE THEORY CORE VALUES

COMPETENCY
Subjective:------- After nursing Independent Margaret Jean Commitment to After nursing
Imbalanced body intervention the Watson’s Vincentian intervention the
Objective: nutrition ( more client will be able  Obtain a Client for the nursing Excellence client was able to:
than body to: thorough intervention of Philosophy and Demonstrate
 Weight: 95 requirement) history. Refer weight management Science of Caring Compassionate appropriate selection
kgs related to diabetes  Demonstrat to dietitian if are adults with no Service of meals or menu
 Sedentary millitus , excess e client has a major health “Her theory stresses planning toward the
lifestyle intake of high- appropriate medical problems who humanistic aspects Co- Responsibility goal of weight
 Eating in calorie food, selection of condition. require diet therapy. of nursing as they reduction
response to Sedentary life and meals or If a patient has a intertwine with
boredom poor dietary menu medical condition scientific knowledge
 Tricep skin habits planning necessitating diety and nursing
fold > 25 mm toward the therapy. practice.”
goal of  Advise patient
weight to measure Measuring food Carl Roger’s
reduction food alerts patient to
regularly. normal portion sizes. Theory of Self
. Estimating amounts Concept in Mental
can be extremely Health Nursing
inaccurate.
 Weigh patient “It highlights the
twice a week It is important to need of nurses to be
under the most patients and aware of their own
same their progress to self when working
conditions. have an actual with clients, a state
reward that the scale that can only be
shows. Monitoring achieved if the
twice a week keeps nurses themselves
the patient on the have adequate
program by not clinical supervision
allowing him or her and an environment
to eat out of control which is supportive
for a couple of days of such work.”
and then fast to lose
weight.
Virginia
Henderson’s
 Allow and Basic Principles of
encourage Moderately intense Nursing Care
patient to physical activity for
adopt an 30 to 45 minutes 5 to “According to her
exercise 7 days/week can individuals have
routine that expend the 1500 to basic needs that are
involves 45 2000 calories/week component of
minutes of that appear to be health and require
exercise five necessary to assistance to
times per maintain weight loss. achieve health and
week. independence.”

“Henderson also
said the unique
function of the
nurse is to assist the
individual, sick or
well”
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS AND CORE THEORY CORE VALUES
COMPETENCY
Subjective: -------- After nursing Independent Margaret Jean Commitment to After nursing
Objective: Decreased Cardiac intervention: Watson’s Vincentian interventions, the
• Lethargic output related to 1. Monitor BP every - Changes in Excellence client has no
• Decreased hypertension as 1. The client will 1-2 hours or every 5 blood Philosophy and elevation in blood
cardiac output evidenced by have no elevation minutes during active pressure may Science of Caring Compassionate pressure above
• Decreased decreased stroke in blood pressure titration of vasoactive indicate Service normal limits and
stroke volume volume above normal drugs. changes in “Her theory stresses has maintain blood
• Increased limits and will patient status humanistic aspects Co- Responsibility pressure within
peripheral maintain blood requiring of nursing as they acceptable limits
vascular pressure within prompt intertwine with
resistance acceptable limits attention scientific knowledge
and nursing
. practice.”
2. Monitor ECG for - Decrease in
dysrhythmias, cardiac Carl Roger’s
conduction defects output may
and for heart rate. result in Theory of Self
changes in Concept in Mental
cardiac Health Nursing
perfusion
causing “It highlights the
dysrhythmias. need of nurses to be
aware of their own
self when working
3. Encourage patient - Caffeine is a with clients, a state
to decrease intake of cardiac that can only be
caffeine, cola and stimulant and achieved if the
chocolates. may adversely nurses themselves
affect cardiac have adequate
function.. clinical supervision
and an environment
which is supportive
of such work.”

4. Observe skin color, - peripheral Virginia

temperature, capillary vasoconstricti Henderson’s
refill time and on may result
diaphoresis in pale, cool, Basic Principles of
clammy skin, Nursing Care
with
prolonged “According to her
capillary individuals have
refill time. basic needs that are
component of
health and require
assistance to
achieve health and
independence.”

“Henderson also
said the unique
function of the
nurse is to assist the
individual, sick or
well”
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS AND CORE THEORY CORE VALUES
COMPETENCY
Subjective:------- After nursing Independent Margaret Jean Commitment to After nursing
Impaired physical intervention the .Provides opportunity Watson’s Vincentian intervention the
Objective: mobility related client will be able • Provide to evaluate healing and Excellence client was able to:
to loss of limb as to: residual limb care on note complications Philosophy and
 Reluctance to evidenced by a routine basis. unless covered y Science of Caring Compassionate • Maintain
reluctance to immediate prosthesis.
attempt  Maintain Service position of function
movement attempt position of “Her theory stresses as evidenced by
movement Measurement is done
 Impaired function as • Measure humanistic aspects Co- Responsibility absence of
to estimate shrinkage
coordination evidenced circumference to ensure proper fit of of nursing as they contractures
 Decreased by absence periodically sock and prosthesis. intertwine with • Demonstrate
muscle of scientific knowledge techniques and
strength contracture • Rewrap Edema will occur and nursing behaviors that enable
s residual limb rapidly, thus delaying practice.” resumption of
 Demonstrat immediately with an rehabilitation. activities; and
e elastic bandage Carl Roger’s • Display
techniques willingness to
• Assist with Prevents contracture Theory of Self participate in
and
specified range of deformities, which can Concept in Mental
behaviors activities
develop rapidly and
that enable motion exercises for Health Nursing
could delay prosthesis
resumption both the affected and usage.
of unaffected limbs “It highlights the
activities; need of nurses to be
and • Provide Prevents external aware of their own
 Display trochanter rolls, as rotation of lower-limb self when working
willingness indicated. residual limb. with clients, a state
to that can only be
• Instruct Strengthens extensor achieved if the
participate
patient to lie prone muscle and prevents nurses themselves
in flexion contracture of
activities. position as tolerated, have adequate
the hip, which can
at least twice a day clinical supervision
begin to develop within
with pillow under 24 hours of sustained and an environment
abdomen and lower- malpositioning. which is supportive
extremity residual of such work.”
limb

• Demonstrate Facilitates self-care Virginia

or assist with transfer and patient’s Henderson’s
techniques and use of independence. Proper
mobility aids such as transfer techniques Basic Principles of
trapeze or a walker. prevent shearing Nursing Care
abrasion/dermal injury
related to “scooting” “According to her
Provides for creation individuals have
of exercise and activity
program to meet
basic needs that are
individual needs and component of
strengths and identifies health and require
mobility functional aid assistance to
to promote achieve health and
independence. independence.”

“Henderson also
said the unique
function of the
nurse is to assist the
individual, sick or
well”
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS AND CORE THEORY CORE VALUES
COMPETENCY
Subjective: -------- After nursing Independent Margaret Jean Commitment to After nursing
Objective: Risk for infection intervention: Watson’s Vincentian interventions, the
• Flushed related to high 1. Observe for signs Patient may be Excellence client was able to
appearance glucose levels, 1. The client will of infection and admitted with Philosophy and identify
• Wound decreased be able to identify inflammation. infection, which Science of Caring Compassionate interventions to
drainage leukocyte interventions to could have Service prevent or reduce
function. prevent or reduce precipitated the keto “Her theory stresses risk of infection
risk of infection acidic state, or may humanistic aspects Co- Responsibility
develop a nosocomial of nursing as they
infection. intertwine with
. scientific knowledge
2. Perform frequent Reduces the risk of and nursing
oral hygiene. cross contamination practice.”

Carl Roger’s

Theory of Self
3. Provide - Peripheral Concept in Mental
conscientious skin circulation may be Health Nursing
care gently impaired.
“It highlights the
need of nurses to be
aware of their own
self when working
with clients, a state
that can only be
achieved if the
4. Maintain aseptic -High glucose in the nurses themselves
technique for IV blood creates an have adequate
insertion procedure, excellent medium for clinical supervision
administration of bacterial growth and an environment
medications, and which is supportive
providing of such work.”
maintenance and site
care. Rotate IV sites
as indicated. Virginia
Henderson’s
Basic Principles of
Nursing Care

“According to her
individuals have
basic needs that are
component of
health and require
assistance to
achieve health and
independence.”

“Henderson also
said the unique
function of the
nurse is to assist the
individual, sick or
well”
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS AND CORE THEORY CORE VALUES
COMPETENCY
Subjective: -------- After nursing Independent Margaret Jean Commitment to After nursing
Objective: Hopelessness intervention: Watson’s Vincentian interventions, the
related to losses, 1. Allow the patient -The process of Excellence client was able to
stressors, and the 1. The client will to express feelings recognizing feelings Philosophy and demonstrate
burdensome demonstrate and perceptions that underlie and Science of Caring Compassionate independent
 Increased symptoms of independent drive behaviors Service problem-solving
sleep depression as problem-solving allows patient to start “Her theory stresses techniques to take
 Lack of evidenced by techniques to take taking control of humanistic aspects Co- Responsibility control over life, and
iniative suicidal thoughts control over life, their lives. of nursing as they does not verbalize or
 Lack of and does not . intertwine with demonstrate
involvement verbalize or -Patients may feel scientific knowledge suicidality.
in care demonstrate hopeless, but it is and nursing
 Passive suicidality. helpful to hear practice.”
 Guarding 2. Express hope to positive expression
behavior the patient with from others. Carl Roger’s
realistic comments
about the patient’s Theory of Self
strengths and Concept in Mental
resources. Health Nursing

“It highlights the

need of nurses to be
aware of their own
self when working
with clients, a state
3. Allow the patient -Helping patient set that can only be
to assume realistic goals achieved if the
responsibility for increases feelings of nurses themselves
self-care, such as control and provides have adequate
setting realistic goals, satisfaction when clinical supervision
scheduling activities, goals are achieved, and an environment
and making thereby decreasing which is supportive
independent feelings of of such work.”
decisions. hopelessness.

Virginia
Henderson’s
 Basic Principles of
Nursing Care

“According to her
individuals have
Dependent basic needs that are
component of
4. Administer -Suicidal thinking is health and require
antidepressants as a symptom of assistance to
indicated. depression that is achieve health and
managed through independence.”
proper medication.
“Henderson also
said the unique
function of the
nurse is to assist the
individual, sick or
well”