Theory-based (Betty Neuman)

NURSING CARE PLAN

Name of Student:________Madaeah Zoei R. Dagondon___________

Client’s Initials:__________________C. C. O____________________ Stressor Classification: (Please check)
Age:_67 yo_Gender: _Male_Civil Status:_Married_Religion:_Roman Catholic_ ______ Physiological (body structure and functions)
Allergies: __________no known food and drug allergies___________ ______ Psychological (mental processes and emotion)
Diet:________________Low Salt, Low Fat Diet__________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission:____________September 9, 2023_____________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:_Non-healing Wound Right Foot secondary to DM Type 2; HPN Stage 2_ ______ Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the shift) (with Rationale & Source)
Subjective: Short-term goal: PRIMARY INTERVENTIONS (focuses on
“Nag-agad kos akong asawa Self-Care Deficit After 8 hours of nursing strengthening the flexible line of defense through preventing
nga mu ilis nako ug sponge related to impaired mobility as intervention, the patient will be stress and reducing risk factors)
bath nako,” as verbalized by evidenced by able to: Promotive:
the patient. ● verbalize knowledge of Determine age and developmental issues
healthcare practices R: To know the affecting ability of individual to
● identify individual participate in own care
Objective: areas of needs and S: (Murr et al., 2012)
● Presence of dirty teeth weaknesses
Review medication regimen
● Not changing of clothes
since yesterday Theoretical basis:
● Dry skin According to the NANDA,
Self-care Deficit is defined as
the impaired ability to perform
or complete bathing, dressing,
feeding, or toileting activities for
self. These self-care tasks are
essential actions that
individuals autonomously
undertake to preserve and
improve their overall well-being.
This diagnosis is common
among patients who have
physical mobility problems as
they lack certain body
functioning that could
contribute to the management
of self. The inability to perform
ADLs can lead to unhygienic
results such as bad breath,
dirty teeth, and continued use
of soiled clothes. (Wayne,
2023)
Long-term goal:
After 16 hours of nursing
intervention, the patient will be
able to:
● demonstrate
techniques and
lifestyle changes to
meet self-care needs
● perform self-care
ability within level of
own ability
R: To know for possible effects on alertness/
mentation, energy level, balance, perception
S: (Murr et al., 2012)
Preventive:
Assess memory and intellectual functioning
R: To note developmental level to which client has
regressed or progressed
S: (Murr et al., 2012)
Determine individual strengths and skills of the
patient
R: To know capacity of patient to do self-care
S: (Murr et al., 2012)
SECONDARY INTERVENTIONS (focuses on
strengthening the internal lines of resistance and protecting
the basic structure through appropriate treatment of
symptoms)
Curative:
Ask client/SO for input on bathing habits or
cultural bathing preferences
R: Creates opportunities for client to (1) keep
long-standing routines (e.g., bathing at bedtime to
improve sleep) and (2) exercise control over
situation. This enhances self-esteem, while
respecting personal and cultural preferences
S: (Murr et al., 2012)

Assist dressing as indicated

R: Client may need assistance in putting on or
taking off items of clothing (e.g., shoes and socks,
or over-the-head shirt) or may require partial or
complete assistance with fastener
S: (Murr et al., 2012)

TERTIARY INTERVENTIONS (focuses on

maintaining wellness or protecting the client system
reconstitution through supporting existing strengths and
continuing to preserve energy)
Rehabilitative:
Review safety concerns
R: To reduce risk of injury and promote successful
community functioning
S: (Murr et al., 2012)

Review and modify program periodically to

accommodate changes in client’s abilities
R: To assist client to adhere to plan of care to
fullest extent
 S: (Murr et al., 2012)

Incorporate family members and caregivers

R: Involving family members, spouses, and other
caregivers promotes a commitment and
understanding of each person’s role to success
S: (Wagner, 2021)

References:
1. __Murr, A. C., Doenges, M. E., & Moorhouse, M. F. (2012). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. F. A. Davis
Company.___
2. __Wayne, G. (2023, July 31). Self-Care Deficit & Activities of Daily Living (ADLs) Nursing Care Plan and Management. Nurseslabs. Retrieved
September 27, 2023, from https://nurseslabs.com/self-care-deficit/___
3. __Wagner, M. (2021, October 14). Self-Care Deficit Nursing Diagnosis & Care Plan. NurseTogether. Retrieved September 27, 2023, from
https://www.nursetogether.com/self-care-deficit-nursing-diagnosis-care-plan/

Nursing Care Plan Product Assessment Rubric

CRITERIA Competent Advance Beginner Novice

All subjective and/or objective cues identified are The subjective and/or objective cues identified include some The subjective and/or objective cues identified include
Assessment aligned, relevant and sufficient in the formulation of data that are misaligned, irrelevant but sufficient enough in several data that are misaligned, irrelevant making it
(3) the nursing diagnosis formulating the nursing diagnosis insufficient in the formulation of the nursing diagnosis
(3) (2) (1)
 The nursing diagnosis is appropriate based on the cues The nursing diagnosis is appropriate based on the cues The nursing diagnosis is inappropriate based on the cues
and the priority complaints of the patient or of the presented but may not necessarily be the priority nursing presented and does not reflect the patient’s response to
Diagnosis (3) case scenario problem based on the patient’s health situation or of the the illness.
(3) case scenario (1)
(2)
All the concepts, models and theories (at least 3) are The concepts, models and theories include some The concepts, models and theories are irrelevant and do
Theoretical relevant and substantially supports the nursing information that are irrelevant to the patient’s case, not substantially support the nursing diagnosis in relation
Basis (2) diagnosis in relation to the patient’s case however, the data (less than 3) still adequately supports the to the patient’s case
(2) nursing diagnosis in relation to the patient’s case (1.5) (1)
Goal/s set is/are specific, measurable, attainable, Goal/s set missed 1-2 elements but the statements are Goal/s set missed 3 or more elements and the statements
Goals/Goal realistic and time-bounded. Includes both short-term aligned to the identified nursing problem. Goal setting are not aligned to the identified nursing problem.
Setting and long-term goals and are aligned to the identified considers both short term and long-term care. (2)
(4) nursing problem. (3)
(4)
All interventions are related and responsive to the Interventions include some data that are unrelated and Interventions include several data that are unrelated and
Interventions identified needs and sufficient to help attain the goal. unresponsive to the identified needs, however, the identified unresponsive to the identified needs which results in the
(5) (5) interventions are sufficient to help attain the goal. non-attainment of the set goal/s.
(4) (3)
The subjective/objective data are aligned, relevant and The subjective/objective data include information that are The subjective/objective data include information that are
Evaluation adequate to assess the attainment of the outcome misaligned, irrelevant but adequate enough to assess the misaligned, irrelevant and are inadequate to assess the
(2) criteria. attainment of the outcome criteria. attainment of the outcome criteria.
(2) (1.5) (1)
At least 3 updated (within 8 – 10 years), accurate and Less than 3 updated (within 8 – 10 years), accurate and References provided are not updated, inaccurate,
References
credible references are provided using APA Format credible references are provided using APA Format (0.5) unreliable or no references provided
(1)
(1) (0)
Total Score

________________________________________
Name and Signature of the Faculty