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NURSING CARE PLAN INFORMATION
ASSESSMENT
Subjective data is information that the client actually tells the nurse during the nursing assessment.
Have a minimum of 4 supporting statements.
Must be pt statements eg. Pt stated: “I can’t take the pain anymore”
“When is it going to be over?”
Objective data is concrete observations or measurements made by the nurse. Have a minimum of 4
observations.
(what you see, hear, smell, or measure) eg. - Pt crying & grips bed during contraction
- Baby in OP position
Include only data that supports to dx. This data is then clustered into patterns of health or
illness that will aid the nurse in identifying an applicable nursing diagnosis.
DIAGNOSIS
*Must be a priority dx
3-part statement.
part 1- Diagnostic Label + part 2 -Related Factors + part 3 -Defining Characteristics
Eg. Inability to cope effectively r/t painful contractions AEB pt statements
ACTUAL PROBLEM
2- part statement
part 1- Diagnostic Label + part 2 - Risk Factors
eg. Potential for ineffective Br r/t indecisiveness about breastfeeding
POTENTIAL
WELLNESS
1 part - Response
eg. Readiness for health teaching
2 part – Response + condition
eg. Health seeking behaviours r/t lack of information about appropriate breastfeeding practices.
GOAL
Helps provide individualized care, promotes client participation, and plans care that is realistic and
measurable. Be realistic in establishing outcomes & make sure the verb is measurable.
Goals consist of 5 parts:
1 SUBJECT + 2 VERB + 3 CONDITION + 4 CRITERIA + 5 SPECIFIC TIME FRAME
eg. The pt (1) will demonstrate (2) when breastfeeding (3) two behaviours indicative of an effective
latch (4) by end of shift (5).
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Examples of measurable verbs:
identify
hold
exercise
describe
demonstrate communicate
perform
share
cough
state
verbalize
discuss
have decrease in
have an absence of
walk
express
relate
have an increase in
INTERVENTIONS
This is a plan of care that will assist the patient to achieve their goals.
A minimum of 4 interventions are required.
Interventions need to be specific eg. what is to be done, who will do it, when it will be done, WHY
you are doing it (this is called the rationale and must be referenced from a textbook or article.)
eg. 1. Provide encouragement, support and acknowledge pt efforts throughout labour experience
R: Effective physical and emotional support provided to women during labour can result in
shorter labours, reduced rate of complications and or surgical or obstetrical inductions, and can
enhance self esteem and satisfaction (Lowdermilk, p. 516).
EVALUATION
Evaluate the GOAL & each INTERVENTION with client response examples.
Answer the following questions:
 Was the GOAL accomplished?
 To what degree was the GOAL accomplished?
 What nursing interventions worked well?
 What nursing interventions should be changed and how?
eg. The goal was achieved as pt appeared calm, relaxing all muscles between contractions & able to
control her breathing throughout first stage of labour.
eg. 1. This intervention was implemented and was effective.
Client was assisted in pushing by support person holding legs and was encouraged “push harder,
that's the way right there”. She exhibited progress by baby descending from 0 station to +2. She
also demonstrated increased satisfaction/reduced anxiety of not being able to push properly by
stating “I can’t believe I’m doing it!”
Based on the answers to these questions, modify the care plan as needed.
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UNSATISFACTORY – ADEQUATE NCP
Subjective data: Client stated she is having a hard time with baby latching. Client stated that she was
very tired from giving birth. Client had Varicella as a child.
REMEMBER TO USE ONLY PT STATEMENTS FOR SUBJECTIVE DATA & INCLUDE
ONLY DATA THAT R/T DX.
Objective data: Primipara, Nipples are red, tender and soft. Administered Acetaminophen 325mg,
U/1, mild rubra, No episiotomy, 36.8˚, 80 bpm, 18, 127/76. TOO MUCH UNRELATED DATA.
INCLUDE ONLY OBSERVATIONS THAT SUPPORT YOUR DX
OVERALL UNSATISFACTORY ASSESSMENT DATA
Nursing Diagnosis- Ineffective breastfeeding r/t lack of knowledge of how to breastfeed AEB by
clients statement of willingness to learn to breastfeed. THIS RATIONALE IS MORE
APPROPRIATE FOR A WELLNESS DX.
APPROPRIATE DX CONSIDERING SUPPORTIVE DATA BUT YOU REQUIRE A PROPER
RATIONALE
Client Outcome- The client will learn to breastfeed effectively by having more knowledge of
breastfeeding by the end of her stay at the hospital. YOUR GOAL SHOULD FOCUS ON THE
SUCCESS OF THE FEED
ADEQUATE GOAL
INTERVENTIONS
1) The student nurse will teach client how to position baby for proper latching to breast BE
SPECIFIC. WHAT WOULD YOU TELL HER EXACTLY?
ADEQUATE INTERVENTION
Rationale: This will allow the baby to get nutrients and for mother to have more comfort,
creates a good milk supply, allows for growth of the baby, and also prevents sore nipples.
GOOD RATIONALE
Reference: Caring for yourself after having your baby. WRHA
EVALUATION
#1) This intervention was implemented partially by the student nurse and partially by the
buddy nurse and was effective. UNSATISFCTORY EVALUATION. YOU NEED TO
EXPLAIN IN MORE DETAIL. WHAT DID YOU SEE OR WHAT DID THE PT SAY
THAT MAKES YOU THINK IT WAS EFFECTIVE?
REMEMBER YOU NEED TO EVALUATE THE GOAL AS WELL AS EACH
INTERVENTION
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GOOD – EXCELLENT NCP
SUBJECTIVE DATA
Pt stated: “My nipples are flat, so it’s hard for the baby to latch on”
“My baby has trouble latching, she either falls asleep or pushes away
OBJECTIVE DATA:
-Pt’s has red, cracked nipples
-Baby’s mouth not opening wide with lips not curled out
GOOD SUPPORTIVE PT STATEMENTS & OBSERVATIONS
DIAGNOSIS
Ineffective breastfeeding r/t infant’s inability to latch correctly onto breast AEB mother’s sore nipples
and infant pushing away. EXCELLENT
GOAL
The patient will demonstrate while breastfeeding the proper latching techniques and the ability to
maintain a good latch throughout a feed before being discharged from the hospital. EXCELLENT
DETAILED 5 PART GOAL
INTERVENTIONS
1. Provide patient knowledge of different techniques that facilitate a proper latch-on. Patient should
assume an appropriate and comfortable position, she should be supporting and slightly compressing
her breast with one hand, patient should always bring the baby to the nipple when the baby’s mouth is
wide open. GOOD INTERVENTION
R: -“She compresses the breast slightly so that an adequate amount of breast tissue is taken into the
mouth with latch-on. Most mothers need to support the breast during feeding for at least the first few
weeks until the infant can stay latched on easily” (Lowdermilk, p ).
-”Initially it is best to use the position that most easily facilitates latch-on while allowing
maximum comfort for the mother” (Lowdermilk, p ).
EXCELLENT RATIONALE
EVALUATION
Goal was met
• Client shows and demonstrates proper latch technique and positioning of baby on her own
without support of nurse
• Client actively notices infant feeding cues and feeds infant on demand
• Client demonstrates proper number of feeds per day and has knowledge of signs infant
dehydration
GOOD
1. This intervention was used & was successful. Patient demonstrated correct positioning of her
infant during cradle and football hold and maintained constant support of her breast with one
hand. She stated “I feel like she is latched better this time, I’ll have to practice more” GOOD
(THESE ARE ONLY PARTIAL CARE PLANS. REMEMBER A MINIMUM OF 4
SUBJECTIVE, 4 OBJECTIVE & 4 INTERVENTIONS ARE REQUIRED
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NCP DIAGNOSIS
Activity/Rest
Activity intolerance (specify level)
Activity intolerance, for
Disuse syndrome, risk for
Diversional activity deficit
Fatigue
Sleep pattern disturbance
Circulation
Adative capacity: intracranial, decreased
Cardiac output, decreased
Dysreflexia
Tissue perfusion, altered (specify): cerebral,
cardiopulmonary, renal, Gastrointestinal, peripheral
Elimination
Bowel incontinence
Constipation
Constipation, colonic
Constipation, perceived
Diarrhea
Incontinence, functional
Incontinence, reflex
Incontinence, stress
Incontinence, total
Incontinence, urge
Urinary elimination, altered
Urinary retention, (acute/chronic)
Food/Fluid
Ego Integrity
Adjustment, impaired
Anxiety (mild, moderate, severe, panic)
Body image disturbance
Coping, defensive
Coping, individual, ineffective
Decisional conflict
Denial, ineffective
Energy field disturbance
Fear
Grieving, anticipatory
Grieving, dysfunctional
Hopelessness
Personal identity disurbance
Post-trauma response (specify stage)
Powerlessness
Rape-trauma syndrome (specify)
Rape-trauma syndrome: compound reaction
Rape-trauma syndrome: silent reaction
Relocation stress syndrome
Self-esteem, chronic low
Self-esteem disturbance
Self-esteem, situational low
Spiritual distress (distress of the human spirit)
Spiritual well being, enhanced, potential for
Breastfeeding, effective
Breastfeeding, ineffective
Breastfeeding, interrupted
Fluid volume deficit (active loss)
Fluid volume deficit (regulatory failure)
Fluid volume deficit, risk for
Fluid volume excess
Infant feeding pattern, ineffective
Nutrition: altered, less than body requirements
Nutrition: altered, more than body requirements
Nutrition: altered, risk for more than body requirements
Oral mucous membrane, altered
Swallowing, impaired
Hygiene
Self-care deficit (specify level): feeding,
bathing/hygiene, dressing/ grooming, toileting
Neurosensory
Confusion, acute
Confusion, chronic
Infant behavior, disorganized
Infant behavior, disorganized, risk for
Infant behavior, organized, potential for enhanced
Memory, impaired
Peripheral neurovascular dysfunction, risk for
Sensory perception alterations (specify): visual, auditory,
kinesthetic, gustatory, tactile, olfactory
Thought processes, altered
Unilateral neglect
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Pain/Discomfort
Pain
Pain, acute
Pain, chronic
Respiration
Airway clearance, ineffective
Aspiration, risk for
Breathing pattern, ineffective
Gas exchange, impaired
Spontaneous ventilation, inability to sustain
Ventilatory weaning response, dysfunctional
(DVWR)
Safety
Body temperature, altered, risk for
Environmental interpretation syndrome, impaired
Health maintenance, altered
Home maintenance management, impaired
Hyperthermia
Hypothermia
Infection, risk for
Injury, risk for
Perioperative positioning injury, risk for
Physical mobility, impaired
Poisoning, risk for
Protection, altered
Self-mutilation, risk for
Skin integrity, impaired
Skin integrity, impaired, risk for
Suffocation, risk for
Thermoregulation, ineffective
Tissue integrity, impaired
Trauma, risk for
Violence, (actual)/risk for:
directed at self/others
Sexuality(component of ego integrity and social
interaction)
Sexual dysfunction
Sexuality patterns, altered
Social Interaction
Caregiver role strain
Caregiver role strain, risk for
Communication, impaired verbal
Community coping, enhanced, potential for
Community coping, ineffective
Family coping, ineffective
Family coping, potential for growth
Family processes, altered: alcoholism (substance abuse)
Family processes, altered
Loneliness, risk for
Parental role conflict
Parent/infant/child attachment, altered, risk
for
Parenting, altered
Parenting, altered, risk for
Role performance, altered
Social interaction, impaired
Social isolation
Teaching/Learning
Growth and development, altered
Health-seeking behaviors (specify)
Knowledge deficit (learning need) (specify)
Noncompliance (compliance, altered) (specify)
Therapeutic regimen: community, ineffective
management
Therapeutic regimen: families, ineffective management
Therapeutic regimen: individual, effective management
Therapeutic regimen: individual, ineffective
management
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WELLNESS DX
Beginning acceptance of reality of pregnancy
Seeking early prenatal care
Increasing joy about being pregnant
Progressive incorporation of physical changes of pregnancy into lifestyle
Progressive acceptance of reality of the fetus
Beginning preparation of environment (nesting) for new infant
Beginning prenatal attachment
Examining relationship with own mother
Developing a working relationship directed toward mutual support during pregnancy & parenting
Recognizing family interdependence
Beginning fantasies about the infant’s personality
Beginning maternal – infant attachment
Resolving conflict between fatasized infant & actual infant
Beginning attainment of mothering role
Integrating fantasy role with actual mothering role
Progressive preparation for labour
Creating a labour plan to communicate personal desires for labour experience
Attaining control during labour
Acquiring role of labour coach
Beginning establishment of breastfeeding
Increasing confidence in infant care skills
Beginning integration of the infant into the family
Beginning adjustment to multiple roles
Adequate oxygen exchange
Maintenance of thermoregulation
Adequate nutritional intake
Progressive transition to extrauterine life
Progressive synchrony with mother
Beginning to elicit caretaking behaviours
Progressive self-comforting behaviour
(from Stolte)