Developing Effective NANDA Nursing Diagnoses for Care Plans
School
Jersey College, School of Nursing **We aren't endorsed by this school
Course
MED SURG 103
Subject
Nursing
Date
Dec 12, 2024
Pages
6
Uploaded by MagistrateFog25526
Care Plan- RNInstructions for particular sections in the document are found in the Blue highlighted rows below. Students are expected to develop three NANDANursing Diagnoses/ Problem-Based Nursing Diagnoseswith supporting documentation. The first Nursing Diagnosis identified should be the prioritynursing diagnosis. This will be the nursing diagnosis used to develop the Care Plan. Before completing the Care Plan below, visit DocuCareand review/chart the client’s assessmentas instructed.Priority- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis•Choose a NANDA or Problem-Based Nursing Diagnosis•The statement should list only one diagnosis and be listed using the following format- problem followed by “Related to (R/T) the disease process/ pathophysiology•Including a statement “As evidenced by clinical manifestations, diagnostic test and labs. •Each statement should be supported by rationaleExample: Coping, ineffective family: R/T Temporary family disorganization and role changes as evidenced by significant other's limited personal communication with client.Write the PRIORITYNursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as evidenced by sentence including rationale below:Deficient fluid vollume related to active fluid loss from bleeding in the esophagus, stomach, or small and large intestions as evidenced by a decrease in blood pressure and altered mental state.#2- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis•Choose a NANDA or Problem-Based Nursing Diagnosis•The statement should list only one diagnosis and be listed using the following format- problem followed by “Related to (R/T) the disease process/ pathophysiology•Including a statement “As evidenced by clinical manifestations, diagnostic test and labs. •Each statement should be supported by rationaleExample: Coping, ineffective family: R/T Temporary family disorganization and role changes as evidenced by significant other's limited personal communication with client.Write the #2Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as evidenced by sentence including rationale below:Deficient knowledge related to patient non-adherent as evidenced by inaccurate follow-through of managementy of Gastric and Peptic ulcer disease.#3- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis•Choose a NANDA or Problem-Based Nursing Diagnosis•The statement should list only one diagnosis and be listed using the following format- problem followed by “Related to (R/T) the disease process/ pathophysiology•Including a statement “As evidenced by clinical manifestations, diagnostic test and labs. •Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as evidenced by significant other's limited personal communication with client.Write the #3Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as evidenced by sentence including rationale below:Fear related to anticipation of pain as evidenced by patient stating they are scared and nervous.Care Plan- Using the Priority Nursing Diagnosis, develop the plan of care.Subjective Summary (Information stated by client)Subjective Datashould be clear, concise and specific to theNursing DiagnosisExample Subjective Data- what the client/family relates, states or reports. Client reports abdominal pain.Objective Summary (Observable)Objective Data should be clear, concise and specific to the Nursing DiagnosisExample Objective Data- what is observed or measured. May include the client’s behavior, vital signs, lung sounds, urine output, laboratory data, diagnostic testing (etc.) as related to the specific nursing diagnosis.Subjective Data:Pt states abdominal pain of 8/10 "I dont feel go and am dizzy""I am scared and nervous""My stomach hurts bad"Objective Data:Bright red bloody emesis and gastric residualBlood type O+Consent form signed and in chartNG tube placement300ml bloody contents removed from stomachAbdomen distended, tender, and hyperactive x4 quads.BP- 82/56O2- 86% RA, 100% 2L NC 3 Types of Stimuli- Roy’s Adaptation TheoryDescribe how the three stimuliare affected by the reviewing the data collected.•Focal stimuliare those which are most immediately confronting the human adaptive system (for example: asthma) •Contextual stimuliare all other stimuli with effect on the focal stimuli (for example: dyspnea while taking a shower)•Residual stimuliare environmental factors with unknown effects on the current situation (for example: belief and thought about not being able to take a shower safely)Describe:1. Gastric and Peptic ulcer2. Abdominal pain when coughing or with movement
3. Verbalizes fear of the bleeding not stopping and will not be able to live.Four Adaptive Modes- Roy’s Adaptation TheoryDescribe the impact of the identified stimuli on the four Adaptive Modes of behavior (physiological, self-concept, role function and interdependence).Regulator Sub-System of Coping- The regulator subsystem is a person’s physiological coping mechanism. The body attempts to adapt via regulation of our bodily processes, including neurochemical and endocrine systems.•Physiological- Behavior in this mode is a manifestation of the physiological activity of all the cells, tissues, organs, & systems of the body. •5 needs serve to promote physiological integrity, (oxygenation, nutrition, elimination, activity and rest, and protection). •4 processes which help maintain physiological integrity (senses, fluid and electrolytes, neuro, and endocrine function)Cognator Sub-System of Coping- The cognator subsystem is a person’s mental coping mechanism. A person uses his brain to cope via self-concept, interdependence, and role function adaptive modes.•Self-Concept- Deals with the person’s beliefs & feelings about himself/herself. Basic underlying need: psychic integrity (physical perceptions, ideals, goals, moral/ethical beliefs)Physical self: How one sees his own physical being •Body sensation: ability to express sensations/feel symptoms •Body image: how one sees himself as a physical being Personal self:How one views his qualities, values, worth •Self-consistency: one’s self-description of qualities; also includes self-organization behavior •Self-ideal/self-expectancy: what one would like to do or be •Moral-ethical-spiritual self: values, beliefs, religion self-esteem: the value one places on himself/herself•Role Function: Involves the position one occupies in society; behaviors associated with one’s position (role) in society. Basic underlying need: social integrityPrimary role: role based on age, sex, developmental stateSecondary role:role(s) a person assumes to complete tasks associated with a primary role or developmental stage Tertiary role:a role freely chosen; temporary; associated with accomplishments of tasks or goals•Interdependence: Associated with one’s relationships and interactions with others and the giving and receiving of love, respect, and value. Basic underlying need: nurturance and affectionSignificant others: intimate relationships (spouse, parent, God) Support systems: less intimate relationships (coworkers, friends) Giving behaviors: giving love, nurturance, affection
Receiving behaviors: receiving/taking in love, nurturance, affectionDescribe:1. Pt. is on NPO diet and receiving fluids for hypovolemia2. Pt. is scared she will not stop bleeding and die3. A retired wife who is the primary homemaker4. She is a spouse that is now having to pause her role and allow her husband to care for her and reverse her roleGoals/ Outcomes (Short-term/ Long-term) including Timelines/ Timeframes•Each client should have one long-term and oneshort-term goal/ outcomes as part of the Care Plan. •Goal/ Outcome statements should be specific (related to the nursing diagnosis/ problem-based nursing diagnosis), measurable, achievable (realistic for the client), clear and concise (don’t use increase or decrease without including baseline data, timelines/ timeframes should be realistic and achievable. •Include a date or time at which the expected outcomes and nursing intervention are achieved orevaluated (should be specific as “by discharge date” or “ongoing”).Definitions:Short-term Goals/ Outcomes: Those goals that are usually met before discharge or before transfer to a less acute level of care.Long-term Goals/ Outcomes:Those goals that may not be achieved before discharge but require continued attention by client and/or significant others as indicated.Short-term Goal:Patient will no longer be hypovolemic by no signs of hypotenstion and inadequate oxygen saturation and removed from supplimental oxygen by end of shift.Long-term Goal:Patient and her husband will verbalize understanding of the causes and prevention of GI bleeds.Nursing Interventions and Scientific Rationales including Best Evidence with ReferencesThreenursing interventions should be identified for the priorityNANDA Nursing Diagnosis/ Problem-based Nursing Diagnosis. Nursing interventions should be concise, clear, specific, individualized and accomplishable to client and/or family and significant other. Interventions should support the identified goals listed above.Scientific rationales should address how the interventions are going to solve the problem identified and/or attain the outcomes. The rationales should be specific to the intervention and summarized in your own words. There should be a rationale for each of the three nursing interventions. Each rationale must be supported by a citation using APA 7thedition. Nursing Intervention #1:
Monitor color, amount, and consistancy of hematemesis and encourage the patient to describe and document un-whitnessed blood loss for total accuracyRationale:Careful assessments of GI bleeding can help determine the exact site of the bleed.Nursing Intervention #2:Monitor the patients intake and output closelyRationale:Urine output of at least 30ml/hr is an indication of adequate renal perfusionNursing Intervention #3:Monitor Blood Pressure for Orthostatic changesRationale:Early identification of orthostatic changes in Blood Pressure guides specific interventions to reduce harm from injury or falls is a common sign and symptom of fluid loss.Evaluation of Interventions (Impact)The Evaluation should address the client’s response to each of the threeinterventions of the priority Nursing Diagnosis and if any modifications were needed. The discussion below should address if the intervention was effective or not and if a change was needed to meet the identified goals.Evaluation Nursing Intervention #1:Pt. recorded to have 300ml of bloody gastric returnEvaluation Nursing Intervention #2:Blood pressure dropped to 86/56 and O2 86% which was corrected after fluidsEvaluation Nursing Intervention #3:After completion of IVF, 30ml or higher was measured for outputReference-Nursing care plansMeg Gulanick, Judith L. Myers
Elsevier 9th edition