Sample nursing diagnosis care plans. Wound Care & Infection Nursing Diagnosis & Care Plan 2022-10-17
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A nursing diagnosis care plan is an important tool for a nurse to use when caring for a patient. It helps the nurse to identify the patient's health problems and to develop a plan of care to address those problems. A nursing diagnosis care plan consists of several components, including the nursing diagnosis, the patient's goals and expected outcomes, the nursing interventions that will be implemented to achieve those goals, and the evaluation methods that will be used to assess the effectiveness of the plan.
One example of a nursing diagnosis care plan is for a patient who is experiencing chronic pain. The nursing diagnosis for this patient might be "pain, chronic," and the patient's goals might include reducing the intensity and frequency of the pain, improving their ability to perform daily activities, and increasing their overall sense of well-being. To achieve these goals, the nurse might recommend a variety of interventions, such as medication management, physical therapy, and relaxation techniques. The nurse might also suggest that the patient keep a pain diary to track their pain levels and any factors that might be contributing to the pain.
Another example of a nursing diagnosis care plan is for a patient who is experiencing difficulty with mobility. The nursing diagnosis for this patient might be "impaired physical mobility," and the patient's goals might include improving their ability to move around and perform activities of daily living, such as bathing and dressing. To achieve these goals, the nurse might recommend physical therapy, assistive devices, and a structured exercise program. The nurse might also suggest that the patient work with a physical therapist to develop a home exercise program to continue their progress after they leave the hospital or nursing facility.
It is important to note that nursing diagnosis care plans are not set in stone and may need to be modified as the patient's condition changes or as new information becomes available. The nurse should regularly assess the patient's progress and make any necessary adjustments to the care plan to ensure that the patient's goals are being met.
In conclusion, nursing diagnosis care plans are an important tool for nurses to use when caring for patients. They help to identify the patient's health problems, set goals and expected outcomes, and implement interventions to address those problems. By regularly reviewing and adjusting the care plan as needed, the nurse can ensure that the patient is receiving the best possible care and working towards their desired outcomes.
Nursing Care Plan Examples
These medications may be used to suppress nonproductive or paroxysmal cough or reduce excess mucus, thereby improving improve overall comfort and rest. Treatment options range from noninvasive bladder training to surgical procedures, depending on the cause. In this post, we have compiled examples of nursing care plans from different hospital settings to see how these documents are used in practice. That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise family, significant other. Disclaimer : this post is only for education purposes only and is not intended as medical advice and any treatment. Palpate the bladder and observe for bladder distention.
Ensures that traction setup is functioning properly to avoid interruption of fracture approximation. Educate the patient for the need to monitor and report any visual disturbances or other sensory changes. Wiping the perineal area from front to back rather than back to front can prevent the travel of normal flora of the anus to the urethra, where they become UTl-causing pathogens. People with prediabetes may eventually have type 2 diabetes if the condition is left untreated. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
Long-term goals are often used for clients who have chronic health problems or live at home, nursing homes, or in extended-care facilities. Impaired Urinary Elimination Impaired urinary elimination is the inability to remove body wastes from the kidneys in urine. Nursing diagnoses handbook: An evidence-based guide to planning care. In Type 1 diabetes, the immune system produces antibodies that destroy the insulin-producing cells of the pancreas, leaving the organ to produce little or no insulin to help transport the glucose into the cells that need it. When the patient is receiving enteral feedings, recommend continuous feeding rather than bolus feeding. Provide small, frequent meals, including dry foods, such as toast or crackers, and foods that are appealing to the client. Finally, implement the interventions and determine if the outcome was met.
Ensure that the patient performs deep breathing with coughing exercises for at least at least q2h. Recognize the risk factors for infection in patients with tracheostomy and intervene as follows: — Recognize the risk factors for infection in patients with tracheostomy and intervene as follows intervene as follows: Risk factors include the presence of underlying lung disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased access of bacteria to the lower respiratory tract, and cross-contamination caused by manipulation of the tracheostomy cannula. The implementation phase means performing the nursing interventions outlined in the care plan. Clinical orthopaedics and related research, 243 , 36-40. Saunders comprehensive review for the NCLEX-RN examination. Topical antibiotics eliminate bacteria, whereas topical antiseptics stop the spread of microbes such as chlorhexidine and iodine solutions.
Gravity and hydrostatic pressure when the patient is semi fowlers position promote perfusion and ventilation-perfusion matching. It is a sudden loss of consciousness and muscle tone due to a temporary insufficient supply of blood flow to the brain. To maintain patient safety and reduce the risk for cross contamination. Obstruction can result from benign prostatic hyperplasia BPH , urinary tract infections UTIs , urethral strictures, or bladder stones, as well as a pelvic mass. In this blog post, we will explore different ways in which medical practitioners can diagnose activity intolerance and provide appropriate intervention measures accordingly, as a way to guide you, the nursing student… This blog post will provide a detailed overview of nursing interventions and care plans for anxiety.
Thus, it will make problem-solving easier. Development of an audit instrument for nursing care plans in the patient record. Providing time for the patient and caregiver to clarify can build trust and decrease misinformation. Help the patient to select appropriate dietary choices to follow a high fiber, low fat diet. Use a pain scale to let the patient communicate the intensity of wound pain. Asepsis in wound care will prevent further contamination of wounds. Nursing References Ackley, B.
Insert an indwelling catheter as required. Initiate or maintain electrical stimulation, if used. Fever Nursing Care Plan 5 Nursing Diagnosis: Hyperthermia related to possible catheter-associated In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis: Fever Nursing Interventions Rationales Collect a urine sample and send to the lab for urinalysis and culture. May promote healing and strengthen the immune system, improve appetite and enhance improve appetite and increase general well-being. Step 1: Assessment The first step in writing an organized care plan includes gathering subjective and objective data.
Impaired Urinary Elimination Nursing Diagnosis And Care Plans Examples
To ensure that the patient does not experience hyperglycemia high blood glucose level or hypoglycemia low blood glucose level , patients are educated to check their blood sugar about 3 to 4 times a day, or more depending on their treatment plan. Aspiration precautions include keeping the operating table at 30 degrees elevation, turning the patient to the side rather than to the back, and using continuous rather than bolus feedings when the patient is receiving enteral feedings. Inform the patient the details about the prescribed medications e. A 4-column care plan format Below is a document containing sample templates for the different nursing care plan formats. Journal of Clinical Nursing, 15 11 , 1376-1382. Orient the patient to the surroundings.
Nursing Care Plan (NCP): Ultimate Guide and Database
The subject is the client, any part of the client, or some attribute of the client i. Palpate the surrounding skin for tenderness or pain. Loss of the integrity of the skin or space around the tube would allow pathogens to enter through the wound or tube. Refer to a dietitian. Length of stay in case it is not their regular department or location.
Wound Care & Infection Nursing Diagnosis & Care Plan
Disability and rehabilitation, 27 18-19 , 1191-1195. Nursing diagnoses handbook: An evidence-based guide to planning care. Note the characteristics of the urine. If the Other complications may include skin problems, hearing impairment, Gestational diabetes may cause the baby to grow overly large, a condition known as macrosomia. To facilitate a better peripheral blood circulation. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals.