NURSING CARE PLAN II.pdf

health

1. NURSING CARE PLAN
By:
Mrs. NgouahOdile
( PhDc. 678277817)
1
ST. LOUIS UNIVERSITY INSTITUTE
12/4/2022

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Definition…
NursingProcessisacriticalthinkingprocessthatprofessional
nursesusetoapplythebestavailableevidencestocaregivingand
promotinghumanfunctionsandresponsestohealthandillness
(AmericanNursesAssociation,2010)
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➢IntroductionNursingprocessisasystematicmethod
ofprovidingcaretoclients.
➢TheNursingprocessisasystematicmethodof
planningandprovidingindividualizednursingcare
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Purposes of nursing process
➢To identify a client’s health status and actual or
potential health care problems or needs.
➢To establish plan to meet the identified need
➢To deliver specific nursing interventions to meet those
needs

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Components of nursing process….
➢Assessment (data, collection)
➢Nursing diagnosis
➢Planning
➢Implementation
➢And evaluation
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Characteristicsof Nursing Process:
➢Cyclic
➢Dynamic nature
➢Client entredonnes
➢Focus on problemsolvingand decisionmaking
➢Interpersonaland collaborative style
➢Universal applicability
➢Use of criticalthinkingand clinicalreasoning.
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ASSESSMENT
➢Collectdata
➢Organizedata
➢Validatedata
➢Document data
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Definition:
Assessmentisthesystematicandcontinuonscollection,
organization,validation,anddocumentationofdata
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Types of assessment
The four different types of assessmentare:
1) Initial nursing assessment
2) Problem-focusedassessment
3) Emergency assessment
4) Time-lapsedreassessment

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1. Initial nursing assessment:
performedwithinspecifiedtime afteradmission.
To establish a completedatabasefor problem
identification.
Example: Nursing admission assessment

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2.Problem-focused assessment,
To determinethe status of specific problemidentification in
earlierassessment
Example: hourlychecking of vital signsof feverpatient.
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3.Emergencyassessment:
Duringemergencysituationtoidentifyanylife
threatening situation.
Example:rapidassessmentofindividual’sairway,
breathingstatus,andcirculationduring.acardiac
arrest
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4.Time-lapsedreassessment:severalmonthsafterinitial
assessmenttocomparetheclient’scurrenthealthstatuswith
thedatapreviouslyobtained.
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Collectionofdata
Datacollectionistheprocessofgatheringinformation
aboutaclient’shealthstatus.Itincludesthehealthhistory,
physicalexamination,resultsoflaboratoryanddignostic
tests,andmaterialcontributedbyotherhealthpersonnel.

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➢Types of data
twotypes: subjective data and objective
SUBJECTIVE: Base on what the patient says
OBJECTIVE : Base on your observation, laboratory data
and vitals signs

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➢Subjective,alsoreferredtoassymptomsorcovertdata,are
clearonlytothepersonaffectedandcanbedescribeonlyby
that person.
Itching,pain,andfeelingofworryareexamplesofsubjective
data

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Objectivedata,alsoreferredtoassignsorovertdata,are
detectablebyanobserverorcanbemeasuredortested
againstanacceptedstandard.
Theycanbeseen,heard,felt,orsmelled,andtheyare
obtainedbyobservationorphysicalexamination.

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Sources of data
sources of data are primary or secondary.
Primary: it is the direct source of information.
The client is the primary source of data

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Secondary:itistheindirectsourceofinformation:
allsourcesotherthantheclientareconsidered
secondarysources.Familymembers,health
professionals,records,laboratoryanddiagnostic
resultsaresecondarysources

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METHODS OF DATA COLLECTION
The methodsuse to collectdata are :
observation,interviewand examination.
Observation: itisthe gatheringdata by usingthe senses.
Vision, smelland hearingare used

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Interview:aninterviewisaplanned
communicationoraconversationwitha
purpose.Therearetwoapproachestointerviewing:
directiveandnondirective.

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Thedirectinterviewishighlystructuredanddirectlyaskthe
questionsandthenursecontrolstheinterview.
Anondirectiveinterview,orrapportbuildinginterviewandthe
nurseclienttocontroltheinterview

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Stages of an interview
An interview has threemajor stages:
1. The openingor introduction
2. The body of development
3. The closing

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Examination:thephysicalexaminationisasystematic
datacollectionmethodtodelecthealthproblem.Toconduct
theexamination,thenurseusestechniquesofinspection,
palpation,percussionandauscultation.

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Organizationof data
The nurse uses a format thatorganizesthe assessment
data systematically. This isoftenreferredto as nursing
health historyor nursing assessmentform

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Validation of data
The information gatheredduringthe assessmentis
«double-checkd» or verifiedto confirmthatitis
accurateand complete

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Documentation of data
To completethe assessmentphase, the nurse records client
data. Accuratedocumentation isessential and shouldinclude
all data collectedabout the client’s health status.

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NURSINGDIAGNOSISis:
“aclinicaljudgmentconcerningahumanresponsetohealth
condition/lifeprocesses,orvulnerabilityforthatresponse,by
an individual,family,group,orcommunity”

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5 kinds of nursing diagnosis
Actual
Risk potential nursing diagnoses
Possible nursing diagnosis
Wellness diagnoses
Syndrome diagnoses

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Actualdiagnoses
Thepersondatabasecontainsevidenceofsignsand
symptomsordefiningcharacteristicsofthediagnoses
3partstatement
PES(Problem+Etiology+Signsandsymptoms)

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Problem:Nanda(NorthAmericannursingDiagnosis
Association),approveNursingDiagnosis
Etiology:writtenasrelatedto=isoftenpartofmedical
diagnosis
Signsandsymptoms:writtenas:“asevidenced
by”=shouldincludeyourassessmentdataofhowdecidedon
thatparticulardiagnosis

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Example of actual nursing diagnosis:
Nursingdiagnosis/Relatedto/asmanifestedby.
Ineffectiveairwayclearance/Relatedto
physiologiceffectofpneumonia/asevidence
byincreasedsputum,coughing,abnormal
breathsounds,tachypneaanddyspnea.

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➢RISKDiagnosis
Thepersonsdatabasecontainsevidence
ofrelated(riskfactorsofdiagnosis,butno
evidenceofdefiningcharacteristics
Problem+Etiology
Riskforimpairedskinintegrity/relatedto
obesityexcessivediaphoresisandconfinement
tobed
Nosignsandsymptoms

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➢Possiblediagnoses
Theperson’sdatabasedoesn’t
demonstratethedefiningcharacteristicsor
relatedfactorsofdiagnosis,butyourown
intuitiontellsyouthediagnosismaybepresent.

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Possiblenursingdiagnosesarestatements
describingasuspectedproblemforwhichadditional
dataareneededtoconfirmorruleoutthe
suspectedproblem.

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➢One part statementand simplynamethe
possible problem
Example:
possible ineffective individualcoping
Possible Chronic Low Self-Esteem
Possible Social Isolation.

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Wellnessdiagnoses
Beingabletodiagnosewellnessdiagnosesisbasedon
recognizingwhenhealthyclientindicatedesiretoachiveahigher
leveloffunctioningarea.
UsepartstatementusetheWordpotentialforenhanced.
Petersaysiwishiwereabetterparents

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Healthpromotiondiagnosis(alsoknownas
wellnessdiagnosis)isaclinicaljudgment
aboutmotivationanddesiretoincreasewell-
being.Healthpromotiondiagnosisis
concernedintheindividual,family,or
communitytransitionfromaspecificlevelof
wellnesstoahigherlevelofwellness.

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Nursingdiagnosis:potentialforenhanced
parenting.
➢Syndromediagnosis
Asyndromediagnosisisaclinicaljudgment
concerningwithaclusterofproblemorrisknursing
diagnosesthatarepredictedtopresentbecauseofa
certainsituationorevent.

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Nursing Diagnoses associatedwithdisuse
syndrome.
Impairedphysicalmobility
Risk for constipation
Risk for alteredrespiratoryfunction.

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Identify what kind of nursing diagnosis
❖Impaired communication /related to language barrier as
evidence by inability to speak or understand English and
use of Spanish
EXERCICE

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Identify if the statement is correct. If not correct
the statement.
Risk for injury related to lack of side rails on bed

45. Therapeutic relationship
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46. OUTLINE
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I-INTRODUCTION
II-DEFINITION OF THEURAPEUTIC NURSE PATIENT
RELATIONSHIP
III-TYPES OF RELATIONSHIP
IV-THEURAPEUTIC RELATIONSHIP

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V-GOALSOFNURSEPATIENTRELATIONSHIP
VI-FACTORS DETERMINING EFFECTIVE NURSE
PATIENT
VII-QUALITIES OF THEURAPEUTIC NURSE PATIENT
RELATIONS
VIII-PHASES OF THEURAPEUTIC NURSE PATIENT
RELATIONSHIP

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TYPES OF RELATIONSHIP

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➢Asocialrelationshipisprimarilyinitiatedforthe
purposeoffriendship,socializationsand
companionship
➢Thecommunicationisusuallycenteredaround
sharingideas,feelingsandexperiencesandmeets
thebasicneedsofpeople.
➢InTherapeuticNursepatientrelationship,the
socialrelationshipmustbelimited

55. INTIMATE RELATIONSHIP
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➢Ahealthyintimaterelationshipinvolvestwopeople
whoareemotionallycommittedtoeachotherand
bothconcernedabouthavingtheirneedsmetand
helpingeachother.
➢Therelationshipmayincludesexualoremotional
intimacyaswellassharingofmutualgoals
➢Ithasnoplaceinthenursepatientrelationship.

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57. THERAPEUTIC RELATIONSHIP
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➢Itfocusesontheneeds,experiences,feelingsand
ideasoftheclient.
➢Theareastobeworkedonareagreedonandthe
outcomesarecontinuallyevaluated.
➢Thenurseusescommunicationskills,personal
strengthsandunderstandingofhumanbehaviourto
interactwiththeclient

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1.Helptounderstandhis/herproblems.
2.Copewithpresentproblems.
3.Identifyemergingproblems.
4.Findoutnewalternativestoproblems
5.Communicate
6.Tryoutnewpatternsofbehaviour
7.Socialize

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➢Self Awareness
➢Attitude towards the patient
➢Ability of developing the rapport

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➢Selfawarenessincludesselfconcept,beliefsand
values.
Ifanursehasapositiveselfconceptaboutherselfshe
willbeconfidentincaringforthepatient.Butifshehas
developedanegativeselfconcept,shewillnotbeable
tohelpthepatient

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Ability of developing the rapport
➢Itisdefinedasarelationshipofmutualsympathyand
understandingespeciallybetweenpatientand
therapist.
➢Theessentialqualitiesfordevelopingrapportare
warmth,genuinenessandempathy

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1.Genuineness (real and honest)
2.Sincerity
3.Respect
4.Love and affection
5.Concern

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5.Listen
6.Empathy (ability to feel with patient)
7.Good communication skills
8.Exploration of problems 10.Self discipline

67. THANK YOU FOR YOUR KIND
ATTENTION
67 12/4/2022