Nursing Care Plan
Nirasharma
NursingCarePlanInstructionandGuidline.docxNursing Care Plan Template
In the care plan template provided, identify 4-6 actual or potential physiological patient problems.
Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).
· This should be specific assessment data e.g. SBP 88mmHg instead of just saying ‘hypotensive’
Identify the optimal outcome that your patient should achieve before they are discharged.
· This should be a specific target that is appropriate for your specific patient e.g. SBP 110-130mm/Hg, urine output > .5mls/kg/hr, GCS 15/15, etc.
Do not include nursing interventions in the template.
Problems may be:
• actual health problems : a health problem that is currently present or occurring and needs intervention to either end or reverses its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.
Examples: Dehydration due to ........
Wound infection related to ......
Acute pain related to ....
Impaired skin integrity due to ....
Inadequate tissue perfusion related to……..
• potential health problems : a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
The patient is ‘at risk of’ falls due to ...
The patient is ‘at risk of’ developing a DVT due to....
The patient is at risk of infection due to………
For potential health problems, please consider that you are identifying the risk based on evaluation of the data you have been given in the case study. As such, the assessment data will be what puts the patient at risk rather than the assessment data the patient would have if they had this problem as an actual problem. For example, the assessment data for an actual DVT will be redness, swelling, pain, heat while the assessment data for a potential DVT might be reduced mobility, low BP, activation of inflammatory response.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
|
Actual or potential problem |
Assessment data |
Nursing outcome |
|
Actual problem: the patient is dehydrated related to decreased fluid intake |
· Low blood pressure (or ↓BP) – SBP 88mmHg · Tachycardia – HR 125bpm · Patient states he is thirsty · Dry mucous membranes · Low urine output – 100mls in 6 hours |
· Patient will return to a normotensive state with a systolic BP between xx and xxmmHg · HR will be between x and x · Lack of reported thirst · Moist mucous membranes evident. · Urine output will be at least xmls/hr |
|
The patient is ‘at risk of’ infection due to compromised host defences
|
· Low neutrophil count · Receiving radiation therapy for cancer |
· Pt will remain free from any nosocomial infection · WCC will remain between x and x · Pt will verbalise how to prevent acquiring infections · Pt’s family, friends, and hospital staff will use appropriate infection control include PPE and HH |
Note: you can use commonly used abbreviations or symbols, e.g. BP for blood pressure.
No marks are allocated to the template, however it is required to be submitted in order to receive a pass grade for this assessment.
