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NURSING DX BEHAVIORAL OBJ. CONTENT METHODS IMPLEMENTATION EVALUATION Knowledge Deficit: Cogitive: Client will I. Wound care 1.one on one 1.Nurse will assess client able to state 3 r/t wound care state 3 parts of A. Importance discussion client's readiness to parts of wound care with sound care by D/C 1. Ability to heal 2.pamphlets on incision learn, prior to initial 75% accuracy 2 times with 100% accuracy 2. Prevention of infect care teach. Session per shift by day 3 of   B. Components 3.video on incisional 2.Nurse will establish hosp. Teaching 1. Removal of old drsg. care trusting relationship with interventions remain  2. In sp ec ti on of woun d 4. Writt en ins tr uc ti on s cl ien t on da y one of on goin g.  3. Cleansing of wound hosp.  4. Wound drsg. 3.Nurse will review C. wound care concepts of wound care  1. Wash hands with while performing drsg.  soap & water x 3 mins chg for client each hosp  2. Apply clean gloves day.  3. Re move drgs b y touc h 4.Nurse will teach client  outside only - closing concepts for 10mins. 2 dirty section inwards. x per shift until  4.Discard in plastic bag discharge.  5.Chg. Gloves 5.Nurse will allow q&a 6.cleanse with 1/2 str. session at each teach  h2o2 & h2o. A llow to session until d/c  air dry 6.Nurse will validate  7.Open sterile gauze clients knowledge for package using sterile correctness at each 10  tech. Do not touch min teaching session 2  inside of drsg. x per shift until  8.Tear 2 strios of tape discharge.  about 6"long.  9.Apply sterile drsg over  incision without touching  incision with hands.  10.Apply tape to top  and bottom of drsg.  11.Discard used equip.  12.wash hands.  ADN/TRANSITION Sample Teaching Plan

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NURSING DX BEHAVIORAL OBJ. CONTENT METHODS IMPLEMENTATION EVALUATION

Knowledge Deficit: Cogitive: Client will I. Wound care 1.one on one 1.Nurse will assess client able to state 3

r/t wound care state 3 parts of A. Importance discussion client's readiness to parts of wound care with

sound care by D/C 1. Ability to heal 2.pamphlets on incision learn, prior to initial 75% accuracy 2 timeswith 100% accuracy 2. Prevention of infect care teach. Session per shift by day 3 of  

 B. Components 3.video on incisional 2.Nurse will establish hosp. Teaching

1. Removal of old drsg. care trusting relationship with interventions remain

  2. Inspection of wound 4.Written instructions client on day one of ongoing.

  3. Cleansing of wound hosp.

  4. Wound drsg. 3.Nurse will review

C. wound care concepts of wound care

  1. Wash hands with while performing drsg.

  soap & water x 3 mins chg for client each hosp

  2. Apply clean gloves day.

  3. Remove drgs by touch 4.Nurse will teach client  outside only - closing concepts for 10mins. 2

dirty section inwards. x per shift until

  4.Discard in plastic bag discharge.

  5.Chg. Gloves 5.Nurse will allow q&a

6.cleanse with 1/2 str. session at each teach

  h2o2 & h2o. Allow to session until d/c

  air dry 6.Nurse will validate

  7.Open sterile gauze clients knowledge for

package using sterile correctness at each 10

  tech. Do not touch min teaching session 2

  inside of drsg. x per shift until  8.Tear 2 strios of tape discharge.

  about 6"long.

  9.Apply sterile drsg over 

  incision without touching

  incision with hands.

  10.Apply tape to top

  and bottom of drsg.

  11.Discard used equip.

  12.wash hands.

 ADN/TRANSITION

Sample Teaching Plan

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NURSING DX BEHAVIORAL OBJ. CONTENT METHODS IMPLEMENTATION EVALUATION

Knowledge Deficit: Affective: Client will I. Feelings re wounds 1.one on one 1.Nurse will assess client able to discuss

r/t wound care discuss feelings re: A.fear re:Ability to heal discussion client's readiness to feelings one on one

wound care by D/C B.queasiness regard 2. Group process learn, prior to initial during each drsg

  necessity to touch area 3. Journal keeping teach. Session change 2x per shift by

  C.possible repulsivness 4. Role playing 2.Nurse will establish 2nd hosp day  by Self & S/O trusting relationship with client unable to discuss

  D.Worry about infection client on day one of hosp feelings in group

II. Validity of feelings 3.Nurse will discuss process. Continue one

 A. Normality of possible feelings client on one disc. Utilize

B.initial feelings may have regarding journal keeping instead

 C.Ability to cope after wound care at each of group process for  

 exposure drsg. chg remainder of hosp. Stay.

4.Nurse will encourage S/O willing to participate

client to verbalize in one on one disc. By

feel ings regarding 2nd hops day. Teaching

wound care throughout interventions remaindressing changes - 2x ongoing.

per shift until discharge.

5.Nurse will allow q&a

session at each teach

session until d/c

6.Nurse will validate

clients feelings regarding

wound care at each

teaching session 2x

/shift until discharge.

7.Nurse will encourages/o participation in

discussion of feelings

regarding wound care 2x

per shift at drsg chg

throughout hospl

8.Nurse will contact

support group for post

hosp. Care to cont.

interventions.

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NURSING DX BEHAVIORAL OBJ. CONTENT METHODS IMPLEMENTATION EVALUATION

knowledge Deficit: psychomotor: client will I.Wound care 1. Demonstrate with 1.Nurse will assess client able to demo

r/t wound care demonstrate wound A.Wound care return demonstration clients readiness to wound care with 50%

care by D/C 1.wash hands with soap learn, prior to initial accuracy by 1st drsg chg

with 100% accuracy & water x3 mins. teach session on 3rd hosp.- teaching

  2.apply clean gloves 2.Nurse will establish interventions remain  3.remove drgs by touch trusting relationship with ongoing.

  outside only -closing client on day one of hosp Or: client able to

dirty section inward. 3.Nurse will demonstrate demonstrate wound

examine drsg. For wound care 2x per shift care with 100%

drainage - color amt, on 1st day of hosp. accuracy by d/c

  smell, consistency 4.Nurse will allow q&a

  4.discard in plastic bag session at each teach

  5.remove. Gloves session until d/c

  6.rewash hands 5.Nurse will encourage

7.Apply sterile gloves client to participate in

  according to sterile wound care by holding  glove technique equip.and applying tape

  8.cleanse with 1/2 str. at each dress. Chg.2x

  h2o2 & h2o. Using per shift on 2nd hosp day

  sterile cotton tip 6.Nurse will assist

  applicators clean in one client with performing

direction only allow to own wound care 1x on

air dry 3rd hosp day.

  9.Open sterile gauze 7.Clent will preform

  package using sterile entire wound care

  tech. Do not touch procedure by 2nd drsg

  inside of drsg. chg on 3rd hosp day  10.Tear 2 strips of tape 8.Nurse will validate

  about 6"long. clients knowledge for Implimentation con't

  11.Apply sterile drsg correctness at each 10 9.Nurse will provide

  over incision without min teaching session 2 client & S/O with written

touching incision with hand x per shift until dischg instructions at d/c

  12.Appply tape to top 8.Nurse will provide

  and bottom of drsg. positive reinforcement for 

  13.Discard used equip. efforts of client at each

  14. wash hands drsg chg.2xper shift