CARE OF MOTHER, CHILD,

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

G.O. | 1
 Perform
 Relate
 State
 List
 Verbalize
 Demonstrate
 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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