Nursing Care Plan 1
DESALES UNIVERSITY
Department of Nursing and Health
Nursing 204
Nursing Care Plan
1) List your client’s significant assessment findings.
a) Subjective:
b) Objective:
2) Cluster your client’s significant assessment findings by functional health patterns.
a) Health Perception/Health Management Pattern
b) Nutritional/Metabolic Pattern
Nursing Care Plan 2
c) Elimination Pattern
d) Activity/Exercise Pattern
e) Sleep/Rest Pattern
f)
Cognitive/Perceptual Pattern
g) Self-Perception/Self-Concept Pattern
h) Role/Relationship Pattern
i)
Sexuality-Reproductive Pattern
j)
Coping-Stress Tolerance Pattern
Nursing Care Plan 3
k) Value-Belief Pattern
3) Using your own words, what general problem areas do you see in this case?
General Problem Area #1:
General Problem Area #2:
4) Develop data clusters for each of the general problems identified in question 3.
General Problem Area #1:
General Problem Area #2:
.
5) From one of the data clusters in question 4, develop at least two tentative nursing diagnoses.
a) Tentative Nursing Diagnosis for Data Cluster #1:
b) Tentative Nursing Diagnosis for Data Cluster #2:
Nursing Care Plan 4
6) Evaluate each of the tentative nursing diagnoses by writing and comparing the definitions, related factors, and signs and symptoms of each
diagnosis.
Tentative Nursing Diagnosis #1:
i)
Definition:
ii)
Related Factors:
iii) Signs and Symptoms:
(1) Subjective:
(2) Objective:
Nursing Care Plan 5
b) Tentative Nursing Diagnosis #2:
i)
Definition:
ii)
Related Factors:
iii) Signs and Symptoms:
(1) Subjective:
(2) Objective:
Nursing Care Plan 6
7) Identify any gaps and inconsistencies in the data cluster that you would need to assess (if there are gaps in the data cluster) or recheck (if
there are inconsistencies in the data cluster) before identifying the most accurate nursing diagnosis.
a) Tentative Nursing Diagnosis #1:
i)
Gaps
ii)
Inconsistencies
b) Tentative Nursing Diagnosis #2:
i)
Gaps
ii)
Inconsistencies
8) Identify the most accurate nursing diagnosis. Explain your selection.
Nursing Care Plan 7
9) Write a complete basic three-part (PES) nursing diagnosis for the diagnosis you have identified.
a) Problem Statement/Diagnostic Label (P) = ___________________________________________________________________________
b) Etiology/Related Factors (E) = _____________________________________________________________________________________
c) Signs/Symptoms or Defining Characteristics (S) = ______________________________________________________________________
10) Write a client goal for your nursing diagnosis that you have identified that is the opposite healthy response of the problem statement
(diagnostic label) of the nursing diagnosis.
11) Write three expected outcomes that will demonstrate that the client goal has been met.
SUBJECT
VERB
CONDITION OR MODIFIER
CRITERION OF DESIRED PERFORMANCE
RATIONALE
12) Write four nursing strategies/interventions that will help achieve the expected outcomes and, consequently, the client goal.
DATE
References:
SEY/sey
January 16, 2001
VERB
CONTENT AREA
TIME ELEMENT
SIGNATURE
RATIONALE