NCM 107

Name of Professor | Week number

SUBJECTIVE
Topic Outline:  This is what your patients tells you.
● Topic I o My head hurts‖ States on scale of 1-10
● Topic II My head hurts at 8.
OBJECTIVE
NURSING CARE PLAN  This is what you see.
DEFINITION o Patient rubbing head.
 Provide a direction for individualized patient TALK TO YOUR PATIENTS
care.  This helps you decide what is really wrong with
 Provide continuity of care for the patient with all your patient. You must listen to know what they
hospital departments. are not telling you.
 Provide documentation on patient and family NURSING DIAGNOSIS
needs.  It is not a medical diagnosis
 Provides acuity for staffing needs.  A nursing diagnosis is the plan of care for your
 Provides reimbursement for insurance which patient which all member of the staff will follow
was started by Medicare and Medicaid and now as they care for the patient.
used by all insurance companies. This is how  It must be individualized for your patient
hospitals and patients receive payment.  The nursing diagnosis – From NANDA-1 list
TYPES OF NURSING CARE PLAN Related To‖ (R/T)- what is causing the nursing
SUBJECTIVE diagnosis.
 What is actually wrong with the patient.  Defining Characteristics- ―AEB‖ ( as
PSYCHOSOCIAL evidenced by) signs and symptoms better known
 Nursing process and Self-Concept as subjective and objective data
RELATED NANDA NURSING DIAGNOSES PATIENT GOALS
 Ineffective Role Performance  A goal is what you want your patient to achieve.
 Body Image Disturbance I has to be measurable with a time frame noted.
 Chronic low self‐esteem  An example is:
 Self‐esteem disturbance o You will graduate in 4 years BSN, pass
 Situational low self‐esteem the NLE Exam, AMEN.
 Personal Identity disturbance HOW TO WRITE GOALS
RISK  Patient centered
 What is your patient at risk for based on their  Clear and concise
nursing diagnosis.  Observable and measurable
 Nursing diagnoses that are in the "risk for"  time limited
categories may not need the AEB portion of the  Realistic
statement, since there is no actual evidence.  One behavior /goal
However, you should avoid using too many "risk  determined by patient, family, nurse together.
for" diagnosis. One or two, out of eight to ten, is MEASURABLE AND NON-MEASURABLE VERBS
acceptable. MEASURABLE
NANDA-1  Identify
 North American Nursing Diagnosis  Describe
Organization-International
 Perform
HOW TO WRITE A CARE PLAN
 Relate
 Begin with a complete assessment of your
 State
patient. Get as much information as possible
from the chart, such as lab data, x-ray reports,  List
physician history and physical exam.  Verbalize
DATA COLLECTION  Demonstrate

GELLIE L.O. | 1
 Share
 Express
 Communicate
 Exercise
 Cough
 Walk
 Stand
 Sit
 Discuss
 Has an increase in
 Has a decrease in
 Has an absence of
NON-MESURABLE
 Know
 Understand
 Appreciate
 Think
 Accept
 Feel
NURSING INTERVENTIONS
 What are you going to do to help your patient
reach their goal. This is what you do daily for
your patient. If you give your paper to a peer,
would they be able to follow your intervention
or plan of care.
 Example:
o If you study hard then you will graduate.
NURSING RATIONAL
 This is the scientific reason you did this for your
patient. You must tell us (cite) where you got
your information. This could be your from your
books or a reliable internet source.

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