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Analyzing Care Plans: Mr. Walters' & Mrs. Smith's Knowledge Deficit & Skin Integrity Risk, Exercises of Nursing

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.

What you will learn

  • What nursing diagnosis relates to Mr. Walters' lack of knowledge, and how does it apply to him specifically?

Typology: Exercises

2021/2022

Uploaded on 09/12/2022

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Individualized
Care Plans
Fully Developed
1
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
pf3
pf4
pf5
pf8

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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

  • Voices lack of

to be performed in the

(readiness to learn).

knowledge

hospital and at home

Rehearsed the things

  • Demonstrates

on the second

to report while in the

readiness to learn

postoperative day.

hospital and after

(attentive,

going home.

expectant)

  • Reluctant to touch

affected area.

  • Asks questions

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

  • This procedure

will cause much pain.

  • Medication is available

every 3 hours and shouldbe taken on days 1and 2 after surgery.

  • Sitz baths are necessary

and should begin the firstday after surgery.

  • A rubber ring will be

placed in the bathtub andhe will sit on it. Thenurse will be inattendance.

  • Understanding of

underlying principles ofcare fosters cooperationand decreases anxiety.The rectum is veryvascular, bleeds easily,and causes much pain.

  • Client comfort is a

priority with the nurse.Suffering is contradictoryto good nursing care.

  • Enhances comfort and aids

healing. Water is acleaning agent that alsoprevents accumulation ofbacteria.

  • Provides a soft cushion.

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

  • A packing is in his

rectum, which will beremoved the secondmorning.

  • He is to continue to wear

the T-binder and will beprovided with a cleanone as needed.

  • He should ask for pain

medication before hehas a bowel movement.

  • His oral medication will

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.

  • The area should be

thoroughly washed afterevery bowel movement.

  • Aids in the absorption of

drainage (bloody orserosanguinous).

  • Keeps dressing in place

and avoids contaminationof wound.

  • Decreases actual pain

and anxiety related tofirst bowel movement.

  • Colace to be given

routinely as a stoolsoftener. Oil retentionenema concentrates inlower bowel andrectum and facilitatespassage of soft stool.

  • Bleeding, infection, and

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

  • Select foods that have

healthy state. Fluids

high vitamin, high

bathe body tissue,

protein, and high

remove waste and

carbohydrate content.

aid in fluid balance.

  • Endeavor to eat as much

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.