Slide 7 - Patient - Nursing Care Plan (Ncp)

8/10/2019 Slide 7 - Patient - Nursing Care Plan (Ncp)

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PATIENT/NURSING CARE PLAN

MODULE 7

Pre-advance level

for S-1 Nursing Students 2008Dien’s

N

C

P



DEFINITION

A nursing care plan outlines the nursingcare to be provided to a patient.

It is a set of actions the nurse willimplement to resolve nursing problemsidentified by assessment.

The creation of the plan is an intermediatestage of the nursing process.

It guides in the ongoing provision ofnursing care and assists in the evaluation ofthat care.



VOC BUL RY

PATIENT / NURSINGCARE PLAN (NCP)

ASSESSMENT (n)

DIAGNOSIS (n)

PLANNING (n)

INTERVENTION (n)

EVALUATION (n)

Rencana asuhan

keperawatan (askep)

Pengkajian

Diagnosis

Perencanaan

Intervensi/tindak. kep.

Evaluasi



haracteristics of the nursing care plan

It focuses on actions which are designed tosolve or minimize the existing problem.

It is a product of a deliberate systematic

process.

It relates to the future.

It is based upon identifiable health and

nursing problems.

Its focus is holistic.

It focuses to meet all the needs of the

service user.



Elements of the plan

In the USA, the nursing care plan may

consist of a NANDA nursing diagnosis with

related factors and subjective and

objective data that support the diagnosis,nursing outcome classifications with

specified outcomes (or goals) to be

achieved including deadlines, and nursingintervention classifications with specified

interventions.



Nursing Process

Care plans are formed using the nursing process:

1. ASSESSMENT

2. DIAGNOSIS3. PLASNNING

4. INTERVENTION

5. EVALUATION



1. ASSESSMENT

First the nurse collects subjective data andobjective data, then organizes the data into a

systematic pattern, such as Marjory Gordon'sGordon's functional health patterns.

This step helps identify the areas in which theclient needs nursing care.

Based on this, the nurse makes a nursingdiagnosis

1



2 DIAGNOSIS

As mentioned above, the full nursing diagnosis also

includes the relating factors and the evidence thatsupports the diagnosis. For example, a nurse may givethe following diagnosis to a patient with pneumonia thathas difficulty breathing: Ineffective Airway Clearancerelated to tracheobronchial infection (pneumonia) andexcess thick secretions as evidenced by abnormalbreath sounds; crackles, wheezes; change in rate anddepth of respiration; and effective cough withsputum.(This Nursing Diagnosis is taken from the list ofNANDA's functional health patterns,Disturbed pattern is"Activity and Exercise pattern")

2



3 PLANNING

After determining the nursing diagnosis, using

the PES (Problem, Etiology, Signs andSymptoms) system, the nurse must state theexpected outcomes (goals).

A common method of formulating the expected

outcomes is to reverse the nursing diagnosis,stating what evidence should be present in theabsence of the problem.

The expected outcomes must also contain agoal date.

Following the example above, the expectedoutcome would be: Effective airway clearance asevidenced by normal breath sounds; no cracklesor wheezes; respiration rate 14-18/min; and no

cough by 01/01/01.3



4 INTERVENTION

After the goal is set, the nursing interventions

must be established.

This is the plan of nursing care to be followed to

assist the client in recovery.

The interventions must be specific, noting howoften it is to be performed, so that any nurse or

appropriate faculty can read and understand the

care plan easily and follow the directions exactly.

An example for the patient above would be:

Instruct and assist client to TCDB (turn, cough,

deep breathe) to assist in loosening and

expectoration of mucous every 2 hours.4





ASSESSMENT DATA PATTERNS 1. Gather all data that leads you to a particular nursing

diagnosis and its resolution and divide this informationinto two lists, subjective data or objective data.

2. Remove any information that is NOT directly linked to theone nursing diagnosis on which you are working.

3. In the Subjective Data list include relevant :

client complaintsdescription of the client's support system

behavioural and nonverbal messages

client awareness of her/his own

abilities / disabilities

disease process

prognosis

health care needs

available resources

1



ASSESSMENT DATA PATTERNS

4. In the objective data list include relevant: – physical assessments including vital signs

– observations of the support system in action

– judgment of the client's readiness for learning,her learning potential, and locus of control

– chart information including lab and test results

2



NURSING DIAGNOSES

1. When writing a plan that includes severaldiagnoses, write the diagnosis with thehighest priority first.

2. A plan must start with the major issues for

that client. For example, if the client is inacute distress over one problem, a plancovering only other minor problems would

show lack of sensitivity on your part.3. Select only diagnoses that are appropriatewith resolution by actions you can take.

1



NURSING DIAGNOSES 4. Write out the three parts of the Nursing Diagnosis

(R.E.D .): – The human Response of the client [wellness response /

problem (anxiety)]

– Etiology or related events / factors, designated as R/T

– Data that is evidence of the diagnosis. You have already

listed this information under Assessment Data Patterns, sosay "as evidenced by the data listed above".

• Note on related factors: Most human responses arerelated to several factors. List them all.

For example : anxiety related to

• new environment,

• separation from usual support system,

• big exam in two days

2





CLIENT GOALS 4. Each goal must state a target date and hour for

evaluation.( The Anxiety Scale will be re administeredin 24 hours : date, hour.)

5. Write at least one "short term goal" for every NursingDiagnosis. This will demonstrate your ability to actuallyhelp a client achieve a goal. To get credit for the

Evaluation section of your Care Plan set a time whenyou will be there to evaluate goal achievement. ( forexample :" by noon today")

6. Some goals that are important for your client are "long

term goals". Write at least one "long term goal" foreach Nursing Care Plan you develop. Your instructorsunderstand that this kind of goal will have a timeframe for evaluation that goes past the due date forthe Care Plan. See the section on Evaluation on how to

word the Evaluation of any "long term goal". 2





EVALUATION OF THE PLAN1. State when you evaluated the goal. This should be the same

time you designated in the Goal Statement earlier. (forexample : " At noon 2/15/98")

2. Use the measures you designated for goal achievement tostate your client's degree of success. (for example : "theclient evaluated her anxiety as 4 on a 10-point scale.")

3. Draw conclusions on the interventions used related to theoutcome. (for example : "Helping the client to talk about herfeelings reduced her sense of isolation .")

4. Consider changes or additions to the interventions that mightimprove goal achievement. (For example: "Studying withthe client before the next examination should reduce heranxiety even more.")

5. For the "long term goal" you write state: "Evaluation of thisgoal is set for (state the date & time). The client has made(no) (some) (significant) progress toward this goal: (describe any movement toward the goal)."



NCP: CHICKEN POX

ASSESSMENT SUBJECTIVE:

“Nilalagnat ako at may mga butlig ako sa buong

katawan” (I have a fever and rashes all over my body) as verbalized by the patient.

OBJECTIVE:

•Warm to touch

•Irritability •Petechiae

•V/S taken as follows:

T: 37.9 P: 93 R: 21 BP: 120/80



Hyperthermia related to viral infection

NCP: CHICKEN POX

DIAGNOSIS



NCP: CHICKEN POX

INFERENCE Chickenpox, also known as varicella, is a highly

contagious and self-limited infection that mostcommonly affects children between 5-10 years ofage. The disease has a worldwide distribution and isreported throughout the year in regions of temperate

climate. The peak incident is generally during themonths of March through May. Lifelong immunityfor chickenpox generally follows the disease. If the

patient's immune system does not totally clear the body of the virus, it may retreat to skin sensory

nerve cell bodies where it is protected from the patient's immune system. The disease shingles (alsoknown as "zoster") represents release of theseviruses down the length of the skin nerve fiber and

produces a characteristic painful rash. Shingles ismost commonly a disease of adults



NCP: CHICKEN POX

PLANNING

After 8 hours of nursing interventions, the

patient will demonstrate temperaturewithin normal range and will experienceno associated complications



NCP: CHICKEN POX

INTERVENTION INDEPENDENT:

Provide isolation or monitor visitors as indicated.

Wash hands with antibacterial soap before or after care ofthe patient.

Encourage patient to cover mouth and nose during coughsor sneezes.

Monitor patient temperature, degree and pattern.

Observe for chills and profuse diaphoresis.

Monitor environmental temperature.

Provide tepid sponge baths, avoiding the use of alcohol.

Encourage to use calamine lotion.

COLLABORATIVE:

Administer antipyretics as indicated.



NCP: CHICKEN POX RATIONALE Body substance isolation should be used for all

infectious patients and patients with diseasestransmitted through air may also need airborne anddroplet precautions.

Reduces the risk of spreading the infection.•Prevents the spread of infection via airborne droplet.

Fever patter aids in the disease process anddiagnosis. Precede temperature spikes in presence of

generalized infection. Room temperature should be altered to maintain

near-normal body temperature. May help reduce the fever. To help reduce the itchiness. Used to reduce the fever by its central action on the

hypothalamus.



NCP: CHICKEN POX

EVALUATION

After 8 hours of nursing interventions, the

patient was able to demonstratetemperature within normal range andexperienced no associated complications.



THANKS for your attention

Practice makes perfect

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Slide 7 - Patient - Nursing Care Plan (Ncp)

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