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prepared byMrs.Hamdia Mohammed
1-Define nursing process 2-Define nursing care plan
3 -List the basic components of the Nursing Process.
3-Enumerate items of planning process.4 -Apply nursing process on situation.
5 -Explain 2 different example from nursing care plan .
The Nursing Process is:A systematic, rational method of planning and providing individualized nursing care.
A written guide, organizing client data into a formal statements of strategies to assist the client achieve optimal health
Assessment
Diagnosis
Planning
Implementing
Evaluating
The Planning process:- In the process of developing client care plans ,
the nurse engages in the following activities: 1- Setting Priorities. 2- Establishing client goals /desire outcomes 3- Selecting nursing interventions 4- Writing individualized nursing interventions
on care plans.
Mrs. Mona Ali have 43 years old, admitted to
hospital in 17-3-1431H. She complain from sharp
chest pain when coughing and dyspnea on exertion.
States unable to carry out regular daily exercise for
past week .Nausea & vomiting associated with
coughing . Assesses own supports as good (e.g.
relationship with husband) is worried about daughter .
States husband will be out of town until tomorrow.
Concerned too about her work and worry about it .
Nursing diagnosi
s
Goal/Desired outcomes
Intervention
Evaluation
1-Ineffective airway clearance Related to viscous secretions as evidenced by pain and fatigue.
Long term goal-:
Respiratory status : Gas exchange.Short term goal-:
-Absence of pallor and cyanosis
-Pt will be able to use of correct breathing /coughing technique
-Productive cough -Lung clear
1- Assess airway for patency.2-Auscultate lungs for presence of normal or abnormal breathing sounds3-Assess changes in V.S4-Assess cough for effectiveness & productivity( color, amount odor& consistency).
The ptDo coughing & breathing exerciseAnd breaths effectively
5-Assist pt in performing coughing & breathing exercise( chest physiotherapy ).
6-Put pt in sitting position ( optimal position)& use of abdominal muscles for more forceful cough .
7-Encourage oral intake of fluids.8- Administer medications( e.g antibiotic,
bronchodilators, expectorants) as ordered.9- Give pt nebulizer treatment if indicated.
Nursing diagnosis
Goal/Desired outcomes
Intervention
Evaluation
2-Deficient fluid volume: intake insufficient to replace fluid loss R/Tvomiting
aeb poor skin turgor
Long term goal-:
Fluid balance.Short term
goal-:-Good skin
turgor-Moist mucous
membranes.-Stating the need
for oral fluid intake.
1 -Assess characteristic of vomiting
)amount , odor, color.(...,
2 -Evaluate fluid status in relation to dietary intake.
3 -Check V.S4-Assess skin
turgor for signs of dehydration .
Pt demonstrateThat he is increase oral fluid intake & return to normal skin turgor .
5-Assess intake & output.6- Monitor serum electrolytes & report abnormal
value.7-Administer antiemetic drug as order. 8- Give pt I.V fluid as replacement therapy if
indicateas doctor ordered.
Nursing diagnosis
Goal/Desired outcomes
InterventionEvaluation
3-Anxiety R/T family and work problems aeb concerns about work and parenting roles.
Long term goal-:
Anxiety control.Short term goal-:
Freely expressing concerns and possible solutions about work and parenting roles.
1 -Reassure the pt.
2 -Maintain a calm manner while interacting with pt.
3 -Provide a quite environment.
4 -Encourage her to talk about
anxious feeling
Pt verbalize that she or he return to normal psycholo-gical status
5- Assist the pt in developing anxiety- reducing skills ( e.g, relaxation, deep breathing , positive visualization ).
6- Assist pt in developing problem solving abilities.- Emphasize the logical strategies pt can use when
experiencing anxious feelings.
Nursing diagnosis
Goal/Desired outcomes
Intervention
Evaluation
4-Risk for interrupted family processesR/Tmother's illness and temporary unavailability of father to provide child care, AEB concerns about parenting roles.
Long term goal-:Family coping .
Short term goal-:
Client and husband communicating effectively and working together to solve problems.
1 -Assess for precipitating events ( illness, life transition, crisis).
2 -Assess family member’s perceptions of the problem .
3 -Evaluate strengths, coping skills & current support systems.
Pt verbalize that she or he return to normal psycholo-gical status
Nursing diagnosis
Patient goal
interventionEvaluation
Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts
Will experience no self care hygiene deficit by 4 days
1-talking with patient2-reassure him3-tell the importance of hygiene …….
Patient list the time of washing arms and legs
Example of writing nursing care plan
Nursing diagnosis
Patient goal
InterventionsEvaluation
Risk for impaired skin integrity r/t decreased mobility
Pt. will experience no any signs of skin breakdown
1 -change position frequently
2-back rub 3-skin care
4-increase fluid intake
5 -increase protein
intake.……
Pt increase daily exercise & change his position continuous.
Example of writing nursing care plan cont.
