Individualized Care Plans Fully Developed

Transcription

1 Appendix Individualized Care Plans Fully Developed A Refer to Chapter 1 The Nursing Process: A Synopsis, p. 32: Two Individualized Care Plans Fully Developed; Care Plan 1 for Mr. John Walters, Care Plan 2 for Mrs. Mary Smith. All nursing actions and behaviors (nursing interventions) should focus on the individual client s assessment. How can you be certain that the assessment in the completed care plan for Mr. John Walters focused on the physical examination, interview, and data collected from the client s chart? Activity 1 Examine the ordered and selected data for Mr. Walters (first column of Individualized Care Plan 1). a. Physical examination (objective data) nonverbal behavior, attentive (body posture) demonstrates genuine concern for knowledge (readiness to learn). b. Interview (subjective data) client states, I have no idea what to do about this condition. c. Data collected from the client s chart: medical diagnosis Hemorrhoidectomy (first postoperative day). 1

2 2 Appendix A How can you be certain that the nursing diagnosis is formulated from what the client says (the subjective data) and what is found during the physical assessment (objective data) and that the nursing diagnosis is named from the NANDA list as it applies to Mr. Walters? Activity 2 Look again at the ordered/selected column and notice that the client is saying that he does not know how to care for his condition and that his nonverbal communication (objective data) confirms his desire for knowledge. Now examine the NANDA list of nursing diagnoses (p. 169) and observe that the diagnosis that relates to lack of knowledge is Knowledge, Deficient. Be sure to relate this diagnosis to the specific information that your client is seeking (read the diagnosis as written in Individualized Care Plan 1). How do you know when your defining characteristics are correct? Remember that the defining characteristics should substantiate your nursing diagnosis and at least three should match your objective subjective data. Activity 3 Examine the defining characteristics in the completed Individualized Care Plan 1. Notice that three characteristics correspond with the objective/subjective data: voiced lack of knowledge, demonstrated readiness to learn, and asked questions. How do you know that the goals relate specifically to Mr. Walters and that they are attainable? Activity 4 Examine the goals column in the care plan for Mr. Walters. Notice that the short-term goal has the client answering the very questions he asked and the long-term goal has him doing what he needs to do in order to care for himself. How do you know that the interventions involve both client and nurse? Activity 5 Examine the nursing interventions for Mr. Walters. Notice that they are quite comprehensive: details are explained to him, the nurse demonstrates the procedures, and he is given the opportunity to perform these tasks. Activity 6 Examine the rationale column of the completed care plan for Mr. Walters. Notice that there is a rationale (a reason) for each intervention but that these can be used for any client with similar nursing interventions.

3 Appendix A 3 Were the stated goals realized for Mr. Walters? Activity 7 Examine the evaluation column of the completed care plan for Mr. Walters. Note that the client now understands what to do (both short term and long term). The long-term results show him performing the procedures he was taught by the second day and repeating what to do while in the hospital and at home (goal met). Activity 8 Examine Care Plan 2 the same way you did for Care Plan 1 and you will realize that Care Plan 2 is sequential and individualized to the 84-year-old client with a nursing diagnosis of Risk for Impaired Skin Integrity.

4 4 CLIENT: Mr. John Walters AGE: 50 Individualized Care Plan 1 for Appendix A Knowledge Deficit MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day) Ordered & Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation Subjective data: Knowledge deficit Short term: Teach the client the Understanding of Short term Client states about self-care after Client will verbalize following underlying principles of goal met: Client I have no idea what hemorrhoidectomy understanding of the This procedure care fosters cooperation interacted in the to do about this evidenced by client s things he needs to do will cause much pain. and decreases anxiety. teaching session, condition; what statement and on the first operation The rectum is very stated, I will do do I do? nonverbal behavior day between 0800 vascular, bleeds easily, those things. (see ordered & and and causes much pain. Objective data: selected data. Medication is available Client comfort is a Long term goal met: Nonverbal behavior Long term: every 3 hours and should priority with the nurse. Self care on second demonstrates genuine Defining Client will demonstrate be taken on days 1 Suffering is contradictory day with little concern for knowing characteristics: techniques that need and 2 after surgery. to good nursing care. assistance. attentive, expectant Voices lack of to be performed in the Sitz baths are necessary Enhances comfort and aids (readiness to learn). knowledge hospital and at home and should begin the first healing. Water is a Rehearsed the things Demonstrates on the second day after surgery. cleaning agent that also to report while in the readiness to learn postoperative day. prevents accumulation of hospital and after (attentive, bacteria. going home. expectant) Reluctant to touch affected area. Asks questions about the condition. A rubber ring will be placed in the bathtub and he will sit on it. The nurse will be in attendance. Provides a soft cushion. Client should not be left alone because of the potential for fainting after general anesthesia, NPO state, decreased food and fluid intake, and possible blood loss. continues

5 CLIENT: Mr. John Walters AGE: 50 Individualized Care Plan 1 for Appendix A Knowledge Deficit (continued) MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day) Ordered & Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation A packing is in his rectum, which will be removed the second morning. He is to continue to wear the T-binder and will be provided with a clean one as needed. He should ask for pain medication before he has a bowel movement. His oral medication will keep his stool soft. An oil retention enema (to soften stool) may be given on day 3 if he does not have a bowel movement. He should eat higher fiber foods. The area should be thoroughly washed after every bowel movement. Aids in the absorption of drainage (bloody or serosanguinous). Keeps dressing in place and avoids contamination of wound. Decreases actual pain and anxiety related to first bowel movement. Colace to be given routinely as a stool softener. Oil retention enema concentrates in lower bowel and rectum and facilitates passage of soft stool. Bleeding, infection, and pain are still possible complications while in the hospital and after discharge. 5

6 6 CLIENT: Mrs. Mary Smith AGE: 84 Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity MEDICAL DIAGNOSIS: Severe weight loss Ordered & Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation Subjective data: Client Risk for impaired skin Short term: Discuss the plan of Understanding of the Short-term goal met: Client states I am skin and integrity. Client s skin will care and the rationale medical and nursing stated, I know how bones. show no signs of for each action with regimen will enhance it is to get a bedsore. Defining impairment between the client client s cooperation. I have had them before; Objective data: characteristics: 0700 and 1500, on (solicit cooperation). I surely do not want Skin dry and intact, Risk factors 09/06/03. any more. warm to touch Immobility Turn every two hours Sheering forces Moisture Long term: Remove sheering against the skin No evidence of redness Height: 5 feet, (diaphoresis) Client s skin will forces at least every will cause irritation or irritation on day 1. 3 inches Variations in remain intact on 4 hours (tighten draw and alter the integrity temperature 09/07/03. sheet, remove debris). on the first defense Weight: 95 pounds (very hot or Gently insert bedpan. (skin). Long-term goal met: No Ideal body weight: very cold) alteration in skin 127 pounds Malnourished Change linen if Moisture encourages integrity. Staff asked Evidence of muscle Age (elder) accidents (wet spots) bacterial growth, to continue the wasting. Impaired circulation occur. causing damage and regimen begun by the Poor skin turgor infection to tissue. student nurse. Trauma (sheering forces: bed sheets, bedpan) Neurological deficits (impaired sensation) continues

7 CLIENT: Mrs. Mary Smith AGE: 84 Individualized Care Plan 2 for Appendix A Risk for Impaired Skin Integrity (continued) MEDICAL DIAGNOSIS: Severe weight loss Ordered & Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation Daily bath and thorough cleansing after urination and defecation. Ambulation at least twice daily. Increase fluid intake daily (start with 2 glasses and increase to 8 daily) Select foods that have high vitamin, high protein, and high carbohydrate content. Endeavor to eat as much as possible (include midmorning and evening snacks). Daily hygienic measures eliminate odors and prevent infections. Activity (exercise) improves the functioning of all organ systems. Proper nutrition strengthens the immune system and helps to maintain a healthy state. Fluids bathe body tissue, remove waste and aid in fluid balance. Reference: Cox, H.C., Hinz, M., Lubno, M. Scott-Tilley, D., Newfield, S., Slater, M., & Sridaromont, K. (2002). Clinical applications of nursing diagnosis. Philadelphia: F.A. Davis. 7

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