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An analysis of two individualized care plans for Mr. John Walters and Mrs. Mary Smith. The plans include ordered and selected data, nursing diagnoses, goals, interventions, rationales, and evaluations. The focus is on ensuring the assessment, nursing diagnoses, and goals are based on both subjective and objective data, and that interventions involve both client and nurse.
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Typology: Exercises
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Appendix
Subjective data:
Knowledge deficit
Short term:
Teach the client the
Short term
Client states
about self-care after
Client will verbalize
following
goal met: Client
“I have no idea what
hemorrhoidectomy
understanding of the
interacted in the
to do about this
evidenced by client’s
things he needs to do
teaching session,
condition; what
statement and
on the first operation
stated, “I will do
do I do?”
nonverbal behavior
day between 0800
those things.”
(see ordered &
and 1000.
Objective data:
selected data.
Long term goal met:
Nonverbal behavior
Long term:
Self care on second
demonstrates genuine
Defining
Client will demonstrate
day with little
concern for knowing—
characteristics:
techniques that need
assistance.
attentive, expectant
to be performed in the
(readiness to learn).
knowledge
hospital and at home
Rehearsed the things
on the second
to report while in the
readiness to learn
postoperative day.
hospital and after
(attentive,
going home.
expectant)
affected area.
about thecondition.
CLIENT: Mr. John Walters
Individualized Care Plan 1 for Appendix A Knowledge Deficit
MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)
Ordered &Selected Data
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
will cause much pain.
every 3 hours and shouldbe taken on days 1and 2 after surgery.
and should begin the firstday after surgery.
placed in the bathtub andhe will sit on it. Thenurse will be inattendance.
underlying principles ofcare fosters cooperationand decreases anxiety.The rectum is veryvascular, bleeds easily,and causes much pain.
priority with the nurse.Suffering is contradictoryto good nursing care.
healing. Water is acleaning agent that alsoprevents accumulation ofbacteria.
Client should not be leftalone because of thepotential for fainting aftergeneral anesthesia, NPOstate, decreased foodand fluid intake, andpossible blood loss.
continues
CLIENT: Mr. John Walters
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
rectum, which will beremoved the secondmorning.
the T-binder and will beprovided with a cleanone as needed.
medication before hehas a bowel movement.
keep his stool soft.An oil retention enema(to soften stool) may begiven on day 3 if he doesnot have a bowelmovement. He shouldeat higher fiber foods.
thoroughly washed afterevery bowel movement.
drainage (bloody orserosanguinous).
and avoids contaminationof wound.
and anxiety related tofirst bowel movement.
routinely as a stoolsoftener. Oil retentionenema concentrates inlower bowel andrectum and facilitatespassage of soft stool.
pain are still possiblecomplications while inthe hospital and afterdischarge.
thorough cleansing
measures eliminate
after urination and
odors and prevent
defecation.
infections.
twice daily.
improves thefunctioning of allorgan systems.
daily (start with 2
strengthens the
glasses and increase
immune system and
to 8 daily)
helps to maintain a
healthy state. Fluids
high vitamin, high
bathe body tissue,
protein, and high
remove waste and
carbohydrate content.
aid in fluid balance.
as possible (includemidmorning and eveningsnacks).
CLIENT: Mrs. Mary Smith
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
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.