Clinical Nursing Care Plan (please use 1 sheet per diagnosis)
Student Name:
Nursing Assessment:
(Pertinent assessment data to determine a Nursing Diagnosis)
Nursing Diagnosis:
(Use assessment data to establish a priority nursing diagnosis)
Goal:
(Broad statement of what the care plan should accomplish)
Expected Outcome:
(Use SMART format: Specific, Measureable, Attainable, Realistic, Timely. Provides the means to determine if the broader goal is met.)
Interventions:
(Select specific nursing interventions to meet the goals set, and to change or maintain health status)
Assessment:
(Achievement of expected outcomes – assess goal achievement and reasons, and set new plan as required)
(Client Reponses and findings – describe why the goal was met or not)
(Further Nursing Actions – readjust nursing care plan as required)
Continuing Care Plan
Please use Canadian English
I have attached the necessary forms to help complete the assignment. You do not need to include a cover page. The images contain the assessment of the current client to help prepare the nursing care plan.
See below for assignment instructions
Instructions
CLIENT ASSESSMENT
Select a continuing-care client to whom you have been assigned. Complete a nursing assessment using the nursing metaparadigm concepts of client, environment, and health.
Follow the “Nursing Assessment Tool: A Systems Approach” to insert assessment findings.
Use the “Nursing Assessment Form” to organize your data.
NURSING CARE PLAN
Use the “Nursing Care Plan” form to complete your care plan. The following elements should be included in your care plan:
Nursing Diagnosis and Planning
Write three (3) nursing diagnoses. Prioritize your nursing diagnoses in order of most important to least important.
The three diagnosis should be 1. Actual 2. Potential 3. Teaching
Write one (1) client goal/expected outcome for each nursing diagnosis.
The client goal must be measurable and include a specific time frame.
Implementation of Nursing Interventions
Write three (3) nursing interventions for each client goal/expected outcome.
Provide evidence from the literature to support your rationale for each nursing
intervention.
Nursing Assessment
Write Assessment criteria for each nursing intervention that would be used to determine if the client achieved each client goal/expected outcome.
* No assignment is submitted in Moodle – Please hand in your assignment to your instructor in the clinical setting.
* * You must achieve a passing grade on your assignment in order to achieve a successful pass for this course.
Here are the newest list of NANDA diagnoses. There are now 244 diagnoses:
PHYSIOLOGICAL DOMAIN
Circulation: Vital and peripheral circulation
-Decreased cardiac output
-Risk for decreased cardiac output
-Risk for decreased cardiac tissue perfusion
-Risk for impaired cardiovascular function
-Ineffective peripheral tissue perfusion
-Risk for ineffective peripheral tissue perfusion
-Risk for unstable blood pressure
Respiration: Ventilation and gas exchange
-Ineffective airway clearance
-Ineffective breathing pattern
-Impaired gas exchange
-Impaired spontaneous ventilation
-Dysfunctional ventilatory weaning response
Physical Regulation: Hematological, immunological, and metabolic regulatory mechanisms
-Risk for adverse reaction to iodinated contrast media
-Risk for allergy response
-Risk for unstable blood glucose level
-Risk for electrolyte imbalance
-Deficient fluid volume
-Risk for deficient fluid volume
-Excess fluid volume
-Risk for imbalanced fluid volume
-Hyperthermia
-Risk for hyperthermia
-Hypothermia
-Risk for hypothermia
-Risk for perioperative hypothermia
-Risk for ineffective thermoregulation
-Neonatal jaundice
-Risk for neonatal jaundice
-Latex allergy response
-Risk for latex allergy response
-Risk for impaired liver function
-Ineffective thermoregulation
-Risk for metabolic imbalance syndrome
Nutrition: Ingestion, digestion, and absorption of nutrients
-Insufficient breast milk
-Ineffective breastfeeding
-Interrupted breastfeeding
-Readiness for enhanced breastfeeding
-Ineffective infant feeding pattern
-Imbalanced nutrition: less than body requirements
-Readiness for enhanced nutrition
-Obesity
-Overweight
-Risk for overweight
-Ineffective adolescent eating dynamic
-Ineffective child eating dynamic
-Ineffective infant eating dynamic
Elimination: Discharge of body waste
-Bowel incontinence
-Constipation
-Risk for constipation
-Perceived constipation
-Chronic functional constipation
-Diarrhea
-Dysfunctional gastrointestinal motility
-Risk for dysfunctional gastrointestinal motility
-Impaired urinary elimination
-Functional urinary incontinence
-Overflow urinary incontinence
-Reflex urinary incontinence
-Stress urinary incontinence
-Urge urinary incontinence
-Risk for urge urinary incontinence
-Urinary retention
-Risk for urinary tract injury
Skin/Tissue: Skin and body tissues involved in structural integrity (Protection)
-Risk for corneal injury
-Impaired dentition
-Risk for dry eye
-Impaired oral mucous membrane
-Risk for impaired oral mucous membrane
-Risk for pressure ulcer
-Impaired skin integrity
-Risk for impaired skin integrity
-Risk for thermal injury
-Impaired tissue integrity
-Risk for impaired tissue integrity
-Risk for vascular trauma
-Risk for dry mouth
-Risk for venous thromboembolism
Neurological Response: Transmission of nerve impulses
-Decreased intracranial adaptive capacity
-Autonomic dysreflexia
-Risk for autonomic dysreflexia
-Disorganized infant behavior
-Readiness for enhanced organized infant behavior
-Risk for disorganized infant behavior
-Risk for peripheral neurovascular dysfunction
-Unilateral neglect
-Neonatal abstinence syndrome
MENTAL DOMAIN
Cognition: Involved with orientation, information processing, and memory
-Acute confusion
-Risk for acute confusion
-Chronic confusion
-Impaired memory
Self-Concept: Concerning self-perception, identity, and self-regulation
-Disturbed body image
-Ineffective denial
-Labile emotional control
-Ineffective impulse control
-Chronic low self-esteem
-Risk for chronic low self-esteem
-Situational low self-esteem
-Risk for situational low self-esteem
-Disturbed personal identity
-Risk for disturbed personal identity
-Readiness for enhanced self-concept
-Sexual dysfunction
-Ineffective sexuality pattern
Mood Regulation:
-Impaired mood regulation
EXISTENTIAL DOMAINTIAL DOMAINiences and life perceptions essential to human health
Comfort: Perceptions of symptoms and experience of suffering
-Anxiety
-Impaired comfort
-Readiness for enhanced comfort
-Death anxiety
-Fear
-Acute pain
-Chronic pain
-Labor pain
-Chronic pain syndrome
-Nausea
-Chronic sorrow
Well-Being: Regarding perception of quality of life, and satisfaction of needs
-Grieving
-Complicated grieving
-Risk for complicated grieving
-Readiness for enhanced hope
-Hopelessness
-Risk for compromised human dignity
-Readiness for enhanced power
-Powerlessness
-Risk for powerlessness
-Spiritual distress
-Risk for spiritual distress
-Readiness for enhanced spiritual well-being
Life Principles: Personal values, beliefs, and religiosity
-Decisional conflict
-Moral distress
-Impaired religiosity
-Readiness for enhanced religiosity
-Risk for impaired religiosity
Coping: Perceptions of coping, coping experiences, and coping strategies
-Ineffective activity planning
-Risk for ineffective activity planning
-Defensive coping
-Ineffective coping
-Readiness for enhanced coping
-Readiness for enhanced decision-making
-Impaired emancipated decision-making
-Readiness for enhanced emancipated decision-making
-Risk for impaired emancipated decision-making
-Post-trauma syndrome
-Risk for post-trauma syndrome
-Rape-trauma syndrome
-Relocation stress syndrome
-Risk for relocation stress syndrome
-Impaired resilience
-Readiness for enhanced resilience
-Risk for impaired resilience
-Stress overload
-Acute substance withdrawal syndrome
-Risk for acute substance withdrawal syndrome
-Risk for complicated immigration transition
FUNCTIONAL DOMAIN
F
Lifespan Processes: The processes of growth, mental development, physical maturation, and aging
-Risk for delayed development
Physical Ability: Audiovisual abilities, sexual function, and mobility
-Impaired bed mobility
-Impaired physical mobility
-Impaired wheelchair mobility
-Impaired sitting
-Impaired standing
-Impaired transfer ability
-Impaired walking
Energy Balance: Energy patterns and abilities.
-Activity intolerance
-Risk for activity intolerance
-Risk for ineffective activity planning
-Deficient diversional activity
-Fatigue
-Insomnia
-Sedentary lifestyle
-Readiness for enhanced sleep
-Sleep deprivation
-Disturbed sleep pattern
-Imbalanced energy field
-Wandering
Communication: Communication skills
-Readiness for enhanced communication
-Impaired verbal communication
Social Function: Social supports, roles, skills, and interactions.
-Risk for loneliness
-Readiness for enhanced relationship
-Ineffective relationship
-Risk for ineffective relationship
-Ineffective role performance
-Impaired social interaction
-Social isolation
Self-Care: Self-care capabilities and home maintenance skills
-Impaired home maintenance
-Bathing self-care deficit
-Dressing self-care deficit
-Feeding self-care deficit
-Toileting self-care deficit
-Readiness for enhanced self-care
-Self-neglect
Health Promotion: Health literacy and health maintenance
-Ineffective health maintenance
-Ineffective health management
-Readiness for enhanced health management
-Frail elderly syndrome
-Risk for frail elderly syndrome
-Ineffective protection
-Risk-prone health behavior
-Deficient knowledge
-Readiness for enhanced knowledge
-Readiness for enhanced health literacy
SAFETY DOMAIN
Violence:
-Risk for other-directed violence
-Risk for self-directed violence
-Risk for female genital mutilation
-Self-mutilation
-Risk for self-mutilation
-Risk for suicide
Health Hazards:
-Risk for aspiration
-Risk for bleeding
-Risk for disuse syndrome
-Risk for falls
-Risk for infection
-Risk for surgical site infection
-Risk for injury
-Risk for perioperative positioning injury
-Risk for shock
-Risk for sudden infant death syndrome
-Risk for suffocation
-Delayed surgical recovery
-Risk for delayed surgical recovery
-Impaired swallowing
-Risk for trauma
Milieu Hazard: Health impacts of economy, housing standard, and working environment
-Contamination
-Risk for contamination
-Risk for poisoning
-Risk for occupational injury
FAMILY DOMAIN
Reproduction: Concerns with fertility and conception, delivery and postpartum phase of childbirth
-Ineffective childbearing process
-Readiness for enhanced childbearing process
-Risk for ineffective childbearing process
-Risk for disturbed maternal–fetal dyad
Caregiving Roles: Caregiving and caregiver functions
-Risk for impaired attachment
-Caregiver role strain
-Risk for caregiver role strain
-Parental role conflict
-Impaired parenting
-Risk for impaired parenting
-Readiness for enhanced parenting
Family Unit: Family coping, family functionality, and family integrity
-Compromised family coping
-Disabled family coping
-Readiness for enhanced family coping
-Ineffective family health management
-Dysfunctional family processes
-Interrupted family processes
-Readiness for enhanced family processes
ENVIRONMENTAL DOMAIN
Community Health: Community health needs, risk populations, and healthcare programs
-Deficient community health management
-Ineffective community coping
-Readiness for enhanced community coping
Doenges, M. Moorhouse, M. (2019) Nurses’ Pocket Guide-Prioritized Interventions, and Rationales (15th ed.) Murr, A. Philadelphia, PA: F.A. Davis
