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
“Mam ayaw lang kaayo og duol Disturbed Body Image After 8 hours of nursing strengthening the flexible line of defense through preventing
og maayo kay baho kaayo related to impaired tissue intervention, the patient will be stress and reducing risk factors)
akong tiil,” as verbalized by the integrity right foot as evidenced able to: Promotive:
patient by verbalized report on altered ● verbalize Evaluate level of client’s knowledge of and anxiety
foot appearance and smell understanding of body related to situation
changes R: May indicate acceptance or nonacceptance of
Objective: ● verbalize acceptance situation
● covered right foot with of self in situation S: (Murr et al., 2012)
plastic
● necrosis of 1st digit of
right foot Theoretical basis:
● foul-smelling odor from According to the definition in
right foot NANDA, disturbed body image
● hiding of right foot is defined as the confusion
under blankets [and/or dissatisfaction] in
mental picture of one’s physical
self. Body image disturbance
can occur when societal values
prioritize physical appearance,
leading to a distorted
perception of one’s own body
especially when the issue is
physically present such as in
the case of the patient with foot
necrosis and foul odor.
Appropriate care for distorted
body image is a significant step
to recovery. (Wayne, 2023)
● verbalize relief of
anxiety and adaptation
to actual/altered body
image
Long-term goal:
After 16 hours of nursing
intervention, the patient will be
able to:
● acknowledge self as an
individual who has
responsibility for self
● recognize and
incorporate body image
change into self-concept
in accurate manner
without negating
self-esteem
Have client describe self, noting what is positive
and what is negative
R: Be aware of how client believes others see self
S: (Murr et al., 2012)
Discuss meaning of loss/change to client
R: A small (seemingly trivial) loss may have a big
impact and change in function (such as immobility
in elderly) may be more difficult for some to deal
with than a change in appearance
S: (Murr et al., 2012)
Preventive:
Listen to client’s comments and responses to the
situation
R: Different situations are upsetting to different
people, depending on individual coping skills and
past experiences
S: (Murr et al., 2012)
Note withdrawn behavior and the use of denial
R: May be normal response to situation or may be
indicative of mental illness
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:
Establish therapeutic nurse-client relationship
R: Conveying an attitude of caring and developing
a sense of trust
S: (Murr et al., 2012)

Visit client frequently and acknowledge the

individual as someone who is worthwhile
R: Provides opportunities for listening to concerns
and questions
S: (Murr et al., 2012)

Work with client’s self-concept, avoiding moral

judgments regarding client’s efforts or progress
R: Positive reinforcement encourages client to
continue efforts and strive for improvement
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:
Provide information at client’s level of acceptance
and in small segments
R: To allow easier assimilation
S: (Murr et al., 2012)

Encourage SO to offer support

R: Knowing that there are constant people who
accept body changes and provide support is
helpful to encourage social engagement and fast
adaptation to the situation
S: (Cumpian, 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. __Cumpian, T. (2021, November 28). Disturbed Body Image Nursing Diagnosis & Care Plan. NurseTogether. Retrieved September 27, 2023, from
https://www.nursetogether.com/disturbed-body-image-nursing-diagnosis-care-plan/___
3. ___Wayne, G. (2023, July 31). Disturbed Body Image Nursing Diagnosis & Care Plan (2023 Update). Nurseslabs. Retrieved September 27, 2023, from
https://nurseslabs.com/disturbed-body-image/____
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