Appendix Individualized A Care Plans Fully Developed

1 IndividualizedCare PlansFully Developed1 Refer to Chapter 1 The nursing Process: A Synopsis, p. 32: Two IndividualizedCare Plans Fully Developed ; care plan 1 for Mr. John Walters, care plan 2 forMrs. Mary nursing actions and behaviors ( nursing interventions) should focus onthe individual client s can you be certain that the assessment in the completed care plan forMr. John Walters focused on the physical examination, interview, and data col-lected from the client s chart?Activity 1 Examine the ordered and selected data for Mr.

2 Walters (first column ofIndividualized care plan 1).a. Physical examination (objective data) nonverbal behavior, attentive(body posture) demonstrates genuine concern for knowledge (readinessto learn).b. Interview (subjective data) client states, I have no idea what to do aboutthis condition. c. Data collected from the client s chart: medical diagnosis Hemor-rhoidectomy (first postoperative day).AAppendixHow can you be certain that the nursing diagnosis is formulated from whatthe client says (the subjective data) and what is found during the physicalassessment (objective data) and that the nursing diagnosis is named from theNANDA list as it applies to Mr.

3 Walters?Activity 2 Look again at the ordered/selected column and notice that the client is sayingthat he does not know how to care for his condition and that his nonverbalcommunication (objective data) confirms his desire for knowledge. Now exam-ine the NANDA list of nursing diagnoses (p. 169) and observe that the diag-nosis that relates to lack of knowledge is Knowledge, sure to relate this diagnosis to the specific information that your clientis seeking (read the diagnosis as written in Individualized care plan 1).

4 How do you know when your defining characteristics are correct?Remember that the defining characteristics should substantiate your nursingdiagnosis and at least three should match your objective subjective 3 Examine the defining characteristics in the completed Individualized care Plan1. Notice that three characteristics correspond with the objective/subjectivedata: voiced lack of knowledge, demonstrated readiness to learn, and do you know that the goals relate specifically to Mr. Walters and thatthey are attainable?

5 Activity 4 Examine the goals column in the care plan for Mr. Walters. Notice that theshort-term goal has the client answering the very questions he asked and thelong-term goal has him doing what he needs to do in order to care for do you know that the interventions involve both client and nurse?Activity 5 Examine the nursing interventions for Mr. Walters. Notice that they are quitecomprehensive: details are explained to him, the nurse demonstrates the pro-cedures, and he is given the opportunity to perform these 6 Examine the rationale column of the completed care plan for Mr.

6 That there is a rationale (a reason) for each intervention but that thesecan be used for any client with similar nursing AWere the stated goals realized for Mr. Walters?Activity 7 Examine the evaluation column of the completed care plan for Mr. that the client now understands what to do (both short term and longterm). The long-term results show him performing the procedures he wastaught by the second day and repeating what to do while in the hospital andat home (goal met).Activity 8 Examine care plan 2 the same way you did for care plan 1 and you will real-ize that care plan 2 is sequential and Individualized to the 84-year-old clientwith a nursing diagnosis of Risk for Impaired Skin data:Knowledge deficitShort term:Teach the client theShort termClient statesabout self- care afterClient will verbalizefollowinggoal met.

7 Client I have no idea whathemorrhoidectomyunderstanding of theinteracted in theto do about thisevidenced by client sthings he needs to doteaching session,condition; whatstatement andon the first operationstated, I will dodo I do? nonverbal behaviorday between 0800those things. (see ordered &and data:selected term goal met:Nonverbal behaviorLong term:Self care on seconddemonstrates genuineDefiningClient will demonstrateday with littleconcern for knowing characteristics:techniques that , expectant Voices lack ofto be performed in the(readiness to learn).)

8 Knowledgehospital and at homeRehearsed the things Demonstrateson the secondto report while in thereadiness to learnpostoperative and after(attentive,going ) Reluctant to touchaffected area. Asks questionsabout : Mr. John WaltersIndividualized care plan 1 for Appendix A Knowledge DeficitAGE: 50 MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)Ordered &Selected DataNursing DiagnosisGoalsInterventionsRationaleEval uation This procedurewill cause much pain. Medication is availableevery 3 hours and should be taken on days 1 and 2 after surgery.

9 Sitz baths are necessaryand should begin the firstday after surgery. A rubber ring will beplaced in the bathtub andhe will sit on it. Thenurse will be inattendance. Understanding ofunderlying principles ofcare fosters cooperationand decreases rectum is veryvascular, bleeds easily,and causes much pain. Client comfort is apriority with the is contradictoryto good nursing care . Enhances comfort and aidshealing. Water is acleaning agent that alsoprevents accumulation ofbacteria. Provides a soft should not be leftalone because of thepotential for fainting aftergeneral anesthesia, NPOstate, decreased foodand fluid intake, andpossible blood : Mr.

10 John WaltersIndividualized care plan 1 for Appendix A Knowledge Deficit (continued)AGE: 50 MEDICAL DIAGNOSIS: Hemorrhoidectomy (first postoperative day)Ordered &Selected DataNursing DiagnosisGoalsInterventionsRationaleEval uation A packing is in hisrectum, which will beremoved the secondmorning. He is to continue to wearthe T-binder and will beprovided with a cleanone as needed. He should ask for painmedication before hehas a bowel movement. His oral medication willkeep his stool oil retention enema(to soften stool) may begiven on day 3 if he doesnot have a bowelmovement.