Nursing Care Plan

NURSING CARE PLAN GUIDE
ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES

DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient.
|ASSESSMENT |PLANNING |EVALUATION |
|Universal Self Care Requisites |Nursing Diagnosis |Expected Outcomes |Nursing Interventions |Rationale |Outcome Assessment |
| | | | | | |
|DEFINTION: |DEFINITION: |DEFINITION: |DEFINITION: |DEFINTION: |DEFINTION: |
| | | | | | |
|(USCR) the category of self-care requites that |Problem: statement of the patient's risk for |Desired or expected outcomes of nursing |Direction for nursing action designed to assist|Scientific principles, theories or concepts |Responses to or results of nursing |
|are basic and common to all humans and are |or actual health problem that the nurse is |diagnosis: |the client and/or significant other to meet the|underlying nursing interventions: |interventions. An assessment of relative data |
|constantly present; these needs must be met to |licensed and accountable to treat. | |expected outcomes. Nursing actions are | |is made. These outcome assessments describe |
|achieve optimal health and well-being. There | |"Patient will" __________________ |specific, realistic, and individualized for a |Document the source with author, title, |how the patient looks, feels or behaves after |
|are eight universal self-care requisites: |Etiology: factors "related to" or "associated |_____________________________ |particular patient. |edition, and page. |nursing action has been implemented. |
| |with" the patient's problem. |_____________________________ | | | |
|(1) AIR | | |Components of nursing actions: | |May include proposed modifications or present |
|(2) FOOD |Symptoms: manifestation of problem identified.|or |1. Precision action verb | |plan for improvement of nursing care. |
|(3) WATER | | |2. Content area | | |
|(4) ELIMINATION | | |a. What-the actual measure performed | | |
|(5) ACTIVITY AND REST | |to_____________________________________________|b. Where - specific area | | |
|(6) SOLITUDE AND | |_________________________________________ |c. How- the means by which measures will be| | |
|SOCIAL INTERACTION | | |adopted | | |
|(7) PREVENTION OF HAZARDS | | |d. When - time element, how long or how | | |
|(8) NORMALCY | | |often the nursing action is to occur | | |
| | | |3. Categories of Interventions | | |
|Self-Care Agency (SCA) - assets or abilities of| | |A - assessment | | |
|an individual to perform self-care. | | |C - care & comfort measures | | |
| | | |T - teaching | | |
|Self-Care Deficit (SCD) - deficit relationship | | | | | |
|that exists when the demand for self-care | | |Independent, dependent, collaborative, and | | |
|exceeds the person's ability to perform | | |supportive - educative nursing actions are to | | |
|self-care. | | |be considered when writing the plan | | |
| | | | | | |
|Nursing System: the series of organized | | | | | |
|concrete action performed by nurses in | | | | | |
|collaboration with the patient. There are | | | | | |
|three types of nursing systems: | | | | | |
|(1) wholly compensatory | | | | | |
|(2) partly compensatory | | | | | |
|(3) supportive-educative | | | | | |

NURSING DIAGNOSIS: NANDA 2003

|AIR |SOLITUDE - SOCIAL ISOLATION |
|RESPIRATION |EGO INTEGRITY |
|Airway clearance, ineffective |Adjustment, impaired |
|Aspiration, risk for |Anxiety, death |
|Breathing pattern, ineffective |Anxiety (specify level) |
|Gas exchange, impaired |Body image disturbed |
|Spontaneous ventilation: inability to sustain |Conflict, decisional (specify) |
|Ventilatory weaning response, dysfunctional |Conflict, parental role |
|Ventilation, impaired spontaneous |Coping, ineffective community |
| |Coping, community, readiness for enhanced |
|WATER |Coping, compromised family |
|CIRCULATION |Coping, disabled family |
|Adaptive capacity intra-cranial, decreased |Coping, family, readiness for enhanced |
|Cardiac output, decreased |Coping, defensive |
|Dysreflexia |Coping, readiness for enhanced |
|Tissue perfusion, ineffective (specify): cerebral, |Denial, ineffective |
|cardio-pulmonary, renal, gastro-intestinal peripheral) |Energy field, disturbed |
| |Fear |
|FLUID |Grieving, anticipatory |
|Fluid volume deficit |Grieving, dysfunctional |
|Fluid volume deficit, risk for |Hopelessness |
|Fluid volume excess |Personal identity disturbed |
|Fluid volume imbalance, risk for |Post trauma response |
|Fluid volume, readiness for enhanced |Powerlessness |
|Oral mucous membranes, impaired |Powerlessness, risk for |
|Swallowing, impaired |Rape-trauma syndrome |
| |Rape-trauma syndrome: compound reaction |
| |Rape-trauma syndrome: silent reaction |
|FOOD |Relocation stress syndrome |
|FOOD/FLUID |Relocation stress syndrome, risk for |
|Breastfeeding, effective |Self-concept, readiness for enhanced |
|Breastfeeding, ineffective |Self-esteem, chronic low |
|Breastfeeding, interrupted |Self-esteem, situational low |
|Dentition, impaired |Self-esteem, situational low, risk for |
|Infant feeding pattern, ineffective |Sorrow, chronic |
|Nausea |Spiritual distress |
|Nutrition, imbalanced: less than body requirements |Spiritual distress, risk for |
|Nutrition, imbalanced: more than body requirements | |
|Nutrition, readiness for enhanced |SOCIAL INTERACTION |
|Nutrition, imbalanced: risk for more than body requirements |Caregiver role strain |
| |Caregiver role strain, risk for |
| |Communication impaired, verbal |
|ELIMINATION |Communication, readiness for enhanced |
|ELIMINATION |Community coping, enhanced, potential for |
|Constipation |Community coping, ineffective |
|Constipation, risk for |Environmental interpretation syndrome, Impaired |
|Constipation, perceived |Failure to thrive, adult |
|Diarrhea |Family coping, ineffective: compromised |
|Incontinence, bowel |Family coping, ineffective: disabling |
|Incontinence, functional (urinary) |Family coping, potential for growth |
|Incontinence, reflex (urinary) |Family process, dysfunctional: alcoholism |
|Incontinence, stress (urinary) |Family processes, interrupted |
|Incontinence, total (urinary) |Family processes, readiness for enhanced |
|Incontinence, urge (urinary) |Loneliness, risk for |
|Incontinence, urge (urinary) risk for |Parent/infant/child attachment impaired, risk for |
|Urinary elimination, impaired |Parenting, impaired |
|Urinary elimination, readiness for enhanced |Parenting, impaired risk for |
|Urinary retention |Parenting, readiness for enhanced |
| |Role performance, ineffective |
| |Role strain, caregiver |
|ACTIVITY/REST |Role strain, caregiver, risk for |
|ACTIVITY/REST |Social interaction, impaired |
|Activity intolerance |Social isolation |
|Activity intolerance, risk for | |
|Disuse syndrome, risk for |NEUROSENSORY |
|Diversional activity deficient |Confusion, acute |
|Fatigue |Confusion, chronic |
|Sleep deprivation |Infant behavior, disorganized |
|Sleep, readiness for enhanced |Infant behavior, disorganized, risk for |
|Sleep pattern disturbed |Infant behavior, organized, potential for enhancement |
|Transfer ability, impaired |Memory, impaired |
|Walking, impaired |Peripheral neurovascular dysfunction, risk for |
| |Sensory-perceptual alterations (specify): visual, auditory, |
|HYGIENE |kinesthetic, gustatory, tactile, olfactory |
|Self-care deficit (specify): feeding, bathing/ hygiene, | |
|dressing/grooming, toileting |SEXUALITY (COMPONENT OF EGO INTEGRITY AND SOCIAL INTERACTION) |
| |Sexual dysfunction |
|PAIN/COMFORT |Sexuality patterns, ineffective |
|Pain, (acute) | |
|Pain, chronic | |
|Injury, risk for | |
|Perioperative positioning injury, risk for |NORMALCY |
|Physical mobility, impaired |EGO INTEGRITY |
|Social isolation |Fear |
| |Grieving, anticipatory |
| |Grieving, dysfunctional |
|HAZARDS |Hopelessness |
|SAFETY |Personal identity disturbed |
|Body temperature, imbalanced, risk for |Post-trauma syndrome |
|Environment interpretation syndrome, impaired |Post-trauma syndrome, risk for |
|Falls, risk for |Spiritual well-being, readiness for enhancement |
|Health maintenance, ineffective | |
|Home maintenance, impaired |TEACHING/LEARNING |
|Hyperthermia |Development, risk for delayed |
|Hypothermia/infection, risk for |Growth and development, delayed |
|Infection: Risk for or actual |Growth, Risk for disproportionate |
|Injury, risk for |Health-seeking behaviors (specify) |
|Latex allergy, response |Knowledge deficient (specify) |
|Latex allergy response, risk for |Knowledge (specify), readiness for enhanced |
|Mobility impaired, physical |Management of therapeutic regime, effective |
|Mobility impaired, bed |Management of therapeutic regime, Ineffective |
|Mobility impaired, wheelchair |Management of therapeutic regime, readiness for enhanced |
|Perioperative positioning injury, risk for |Management of therapeutic regimen: Community, ineffective |
|Physical mobility, impaired |Management of therapeutic regimen: family ineffective |
|Poisoning, risk for |Non-compliance (compliance, altered) (specify) |
|Protection, ineffective | |
|Self-mutilation | |
|Self-mutilation, risk for | |
|Skin integrity, impaired | |
|Skin integrity, impaired, risk for |NANDA 2004 |
|Sudden infant death syndrome, risk for | |
|Suffocation, risk for | |
|Thermoregulation ineffective | |
|Tissue integrity, impaired | |
|Trauma, risk for | |
|Violence, other directed, risk for | |
|Violence, self directed, risk for | |
|Wandering | |
| | |
|NEUROSENSORY | |
|Confusion, acute | |
|Confusion, chronic | |
|Infant behavior, disorganized | |
|Infant behavior, disorganized, risk for | |
|Infant behavior, organized, readiness for enhanced | |
|Memory, impaired | |
|Neglect, unilateral | |
|Peripheral neurovascular dysfunction, risk for | |
|Sensory-perceptual disturbed (specify): visual, auditory, | |
|kinesthetic, gustatory, tactile, olfactory | |
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