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Nursing care plan

A nursing care plan outlines the nursing care to be provided to a patient. It is a set of actions the nurse will implement to resolve nursing problems identified by assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the nursing care plan


1. It focuses on actions which are designed to solve or minimize the existing problem. 2. It is a product of a deliberate systematic process. 3. It relates to the future. 4. It is based upon identifiable health and nursing problems. 5. Its focus is holistic.
6. It focuses to meet all the needs of the service user.

Elements of the plan


In the USA, the nursing care plan may consist of a NANDA nursing diagnosis with related factors and subjective and objective data that support the diagnosis, nursing outcome classifications with specified outcomes (or goals) to be achieved including deadlines, and nursing intervention classifications with specified interventions.

The nursing process


Care plans are formed using the nursing process. First the nurse collects subjective data and objective data, then organizes the data into a systematic pattern, such as Marjory Gordon's Gordon's functional health patterns. This step helps identify the areas in which the client needs nursing care. Based on this, the nurse makes a nursing diagnosis. As mentioned above, the full nursing diagnosis also includes the relating factors and the evidence that supports the diagnosis. For example, a nurse may give the following diagnosis to a patient with pneumonia that has difficulty breathing: Ineffective Airway Clearance related to tracheobronchial infection (pneumonia) and excess thick secretions as evidenced by abnormal breath sounds; crackles, wheezes; change in rate and depth of respiration; and effective cough with sputum.(This Nursing Diagnosis is taken from the list of NANDA's functional health patterns,Disturbed pattern is "Activity and Exercise pattern")

After determining the nursing diagnosis, using the PES (Problem, Etiology, Signs and Symptoms) system, the nurse must state the expected outcomes, or goals. A common method of formulating the expected outcomes is to reverse the nursing diagnosis, stating what evidence should be present in the absence of the problem. The expected outcomes must also contain a goal date. Following the example above, the expected outcome would be: Effective airway clearance as evidenced by normal breath sounds; no crackles or wheezes; respiration rate 14-18/min; and no cough by 01/01/01. After the goal is set, the nursing interventions must be established. This is the plan of nursing care to be followed to assist the client in recovery. The interventions must be specific, noting how often it is to be performed, so that any nurse or appropriate faculty can read and understand the care plan easily and follow the directions exactly. An example for the patient above would be: Instruct and assist client to TCDB (turn, cough, deep breathe) to assist in loosening and expectoration of mucous every 2 hours. The evaluation is made on the goal date set. It is stated whether or not the client has met the goal, the evidence of whether or not the goal was met, and if the care plan is to be continued, discontinued or modified. If the care plan is problem-based and the client has recovered, the plan would be discontinued. If the client has not recovered, or if the care plan was written for a chronic illness or ongoing problem, it may be continued. If certain interventions are not helping or other interventions are to be added, the care plan is modified and continued. Since its inception, the nursing process has been developed and honed by different authors. Additional detail has been added for each stage of the process, and new or adapted stages have also been suggested. The most recent 'repackaging' of the nursing process comes in the form of the ASPIRE approach to planning and delivering care[1]. This approach - developed within Hull University (UK) as a teaching and learning tool - takes the 5-stage approach outlined above and enhances it. 'Diagnosis' is retitled 'Systematic Nursing Diagnosis' to reflect the process of diagnosis in addition to the final product. An additional stage - 'Recheck' - is placed between Implementation and Evaluation, and reflects the informationgathering activities carried out by nurses, necessary to make an informed judgement about the effectiveness of patient care. There are also care plans written for "at risk" problems, as well as "wellness" care plans. These follow a similar format, only designed to prevent problems from happening and continue or promote healthy behavior.

Assessment
is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used. The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".

A nursing diagnosis
is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care. Nursing diagnoses are developed based on data obtained during the nursing assessment.

Process of diagnoses
1. Collect data - statistical data relevant to achieving a diagnosis. 2. Cues/patterns - changes in physical status. (for example: lower

urinary output)
3. Hypothesis - possible alternatives that could have caused

previous cues/patterns.
4. Validation - taking necessary steps to rule out other

hypothesis, to single out one problem.


5. Diagnosis - making a decision on the problem based on

validation.
6. Strategies - taking necessary action to solve the problem

and/or to provide adequate nursing care.

NCP Nursing Diagnosis: Deficient Fluid Volume Hypovolemia; Dehydration


Nursing Diagnosis: Deficient Fluid Volume Hypovolemia; Dehydration NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels

* Fluid Balance * Hydration

NIC Interventions (Nursing Interventions Classification) Suggested Labels


* Fluid Monitoring * Fluid Management * Fluid ResuscitationNANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially lifethreatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances. * * * * * * * * * * * * * * * Defining Characteristics: Decreased urine output Concentrated urine Output greater than intake Sudden weight loss Decreased venous filling Hemoconcentration Increased serum sodium Hypotension Thirst Increased pulse rate Decreased skin turgor Dry mucous membranes Weakness Possible weight gain Changes in mental status

* * * * * *

Related Factors: Inadequate fluid intake Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea) Failure of regulatory mechanisms Electrolyte and acid-base imbalances Increased metabolic rate (fever, infection) Fluid shifts (edema or effusions)

* Expected Outcomes Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor.

Ongoing Assessment
* Obtain patient history to ascertain the probable cause of the fluid disturbance. This can help to guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition, large amount of drainage post-surgery, or persistent diarrhea. * Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at the same time of day. This facilitates accurate measurement and follows trends. * Evaluate fluid status in relation to dietary intake. Determine if patient has been on a fluid restriction. Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods. * Monitor and document vital signs. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak, and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia. * Monitor blood pressure for orthostatic changes (from patient lying supine to high-Fowlers). Note the following orthostatic hypotension significance: o Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%. o Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%. * Assess skin turgor and mucous membranes for signs of dehydration. The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue. * Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine denotes fluid deficit. * Monitor temperature. Febrile states decrease body fluids through perspiration and increased respiration.

* Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output. * Monitor serum electrolytes and urine osmolality and report abnormal values. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased. * Document baseline mental status and record during each nursing shift. Dehydration can alter mental status. * Evaluate whether patient has any related heart problem before initiating parenteral therapy. Cardiac and elderly patients often have precarious fluid balances and are prone to develop pulmonary edema. * Determine patients fluid preferences: type, temperature (hot or cold). * During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough). This prevents complications associated with therapy. * If hospitalized, monitor hemodynamic status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available. This direct measurement serves as optimal guide for therapy.

Therapeutic Interventions
* Encourage patient to drink prescribed fluid amounts. o If oral fluids are tolerated, provide oral fluids patient prefers. Place at bedside within easy reach. Provide fresh water and a straw. Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink). Oral fluid replacement is indicated for mild fluid deficit. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink. * Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate. * Plan daily activities. Planning prevents patient from being too tired at mealtimes. * Provide oral hygiene. This promotes interest in drinking. * For more severe hypovolemia: Obtain and maintain a large-bore intravenous (IV) catheter. Parenteral fluid replacement is indicated to prevent shock. * Administer parenteral fluids as ordered. Anticipate the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs.

* Administer blood products as prescribed. These may be required for active GI bleeding. * Assist the physician with insertion of a central venous line and arterial line as indicated. This allows more effective fluid administration and monitoring. * Maintain IV flow rate. o Should signs of fluid overload occur, stop infusion and sit patient up or dangle. These decrease venous return and optimize breathing. Elderly patients are especially susceptible to fluid overload. * Institute measures to control excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered). * Once ongoing fluid losses have stopped, begin to advance the diet in volume and composition. * For hypovolemia due to severe diarrhea or vomiting, administer antidiarrheal or antiemetic medications as prescribed, in addition to IV fluids.

Education/Continuity of Care
* Describe or teach causes of fluid losses or decreased fluid intake. * Explain or reinforce rationale and intended effect of treatment program. * Explain importance of maintaining proper nutrition and hydration. * Teach interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits. * Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved. * If patients are to receive IV fluids at home, instruct caregiver in managing IV equipment. Allow sufficient time for return demonstration. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. In addition, elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy

NCP PNEUMONIA
Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. Primary pneumonia is caused by the patients inhaling or aspirating a pathogen. Secondary pneumonia ensues from lung damage caused by the spread of bacteria from an infection elsewhere in the body. Likely causes include various infectious agents, chemical irritants (including gastric reflux/aspiration, smoke inhalation), and radiation therapy. This plan of care deals with bacterial and viral pneumonias, e.g., pneumococcal pneumonia, Pneumocystis carinii, Haemophilus influenzae, mycoplasma, and Gram-negative microbes.

CARE SETTING
Most patients are treated as outpatients; however, persons at higher risk (e.g., with ongoing/chronic health problems) are treated in the hospital, as are those already hospitalized for other reasons.

RELATED CONCERNS
AIDS Chronic obstructive pulmonary disease (COPD) and asthma Psychosocial aspects of care Sepsis/septicemia

Surgical intervention Patient Assessment Database

ACTIVITY/REST
May report: Fatigue, weakness Insomnia May exhibit: Lethargy Decreased tolerance to activity

CIRCULATION
May report: History of recent/chronic heart failure (HF) May exhibit: Tachycardia Flushed appearance or pallor

Eg O INTEGRITY
May report: Multiple stressors, financial concerns

FOOD/FLUID
May report: Loss of appetite, nausea/vomiting May exhibit: Distended abdomen Hyperactive bowel sounds Dry skin with poor turgor Cachectic appearance (malnutrition)

NEUROSENSORY

May report: Frontal headache (influenza) May exhibit: Changes in mentation (confusion, somnolence)

PAIN/DISCOMFORT
May report: Headache Chest pain (pleuritic), aggravated by cough; substernal chest pain (influenza) Myalgia, arthralgia May exhibit: Splinting/guarding over affected area (patient commonly lies on affected side to restrict movement)

RESPIRATION
May report: History of recurrent/chronic URIs, tuberculosis or COPD, cigarette smoking Progressive dyspnea Cough: Dry hacking (initially) progressing to productive cough May exhibit: Tachypnea; shallow grunting respirations, use of accessory muscles, nasal flaring Sputum: Scanty or copious; pink, rusty, or purulent (green, yellow, or white) Percussion: Dull over consolidated areas Fremitus: Tactile and vocal, gradually increases with consolidation Pleural friction rub Breath sounds: Diminished or absent over involved area, or bronchial breath sounds over area(s) of consolidation; coarse inspiratory crackles Color: Pallor or cyanosis of lips/nailbeds

SAFETY May report: Recurrent chills History of altered immune system: i.e., systemic lupus erythematosus (SLE), AIDS, steroid or chemotherapy use, institutionalization, general debilitation Fever (e.g., 1028F1048F/398C408C) May exhibit: Diaphoresis Shaking Rash may be noted in cases of rubeola or varicella TEACHING/LEARNING May report: History of recent surgery; chronic alcohol use; intravenous (IV) drug therapy or abuse; immunosuppressive therapy Discharge plan DRG projected mean length of inpatient stay: 4.38.3 days Assistance with self-care, homemaker tasks. Oxygen may be needed, especially if recovery is prolonged or other predisposing condition exists. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear. Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).

ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung involvement and underlying lung disease. Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, ahemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia. CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated. Serologic studies, e.g., viral or Legionella titers, cold agglutinins: Assist in differential diagnosis of specific organism. Pulmonary function studies: Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia). Electrolytes: Sodium and chloride levels may be low. Bilirubin: May be increased. Percutaneous aspiration/open biopsy of lung tissues: May reveal typical intranuclear and cytoplasmic inclusions (CMV), characteristic giant cells (rubeola).

NURSING PRIORITIES
1. 2. 3. 4. Maintain/improve respiratory function. Prevent complications. Support recuperative process. Provide information about disease process/prognosis and treatment.

DISCHARGE GOALS

1. 2. 3. 4. 5.

Ventilation and oxygenation adequate for individual needs. Complications prevented/minimized. Disease process/prognosis and therapeutic regimen understood. Lifestyle changes identified/initiated to prevent recurrence. Plan in place to meet needs after discharge.

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