Download Analyzing Care Plans: Mr. Walters' & Mrs. Smith's Knowledge Deficit & Skin Integrity Risk and more Exercises Nursing in PDF only on Docsity!
Individualized
Care Plans
Fully Developed
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 col-
lected 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—Hemor-
rhoidectomy (first postoperative day).
A
Appendix
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 exam-
ine the NANDA list of nursing diagnoses (p. 169) and observe that the diag-
nosis 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 pro-
cedures, 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.
2 Appendix A
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
AGE: 50
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.
- Enhances comfort and aids
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)
AGE: 50
MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)
Ordered &Selected Data
Nursing Diagnosis
Goals
Interventions
Rationale
Evaluation
rectum, which will beremoved the secondmorning.
- He is to continue to wear
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.
- Aids in the absorption of
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.
- Daily bath and
- Daily hygienic
thorough cleansing
measures eliminate
after urination and
odors and prevent
defecation.
infections.
- Ambulation at least
- Activity (exercise)
twice daily.
improves thefunctioning of allorgan systems.
- Increase fluid intake
- Proper nutrition
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)
AGE: 84
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.
