TRIBE MEETING: Homework Assignment - MAX SUBMISSIONS ACHIEVED

  1. Only the first 5 submissions will be reviewed
  2. Don't worry if yours isn't one of the 5! You will still learn from others
  3. If you can't make the meeting, DON"T FREAK OUT!...all tribe meetings are recorded and put into the members area
  4. Review the 2 Minute Templates BEFORE writing your care plans below
  5. Review the Assignment Kardex below the 2 Minute Templates and then fill out your PLANNING and EVALUATION Nursing Care Plan

CLICK ON ONE OF THE NURSING DIAGNOSIS TABS ABOVE TO DISCOVER THE “2 MINUTE TEMPLATE”

(super easy!)

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED PHYSICAL MOBILITY”? Here are some examples:

1} In report it was noted that patient has weakness during ambulation

2} In report it was noted that patient verbalized feeling unsteadiness during ambulation

3} In the chart it was noted that patient has an unsteady gait during ambulation

4} In report it was noted that patient unable to ambulate without assistive device (cane, walker, nurse, etc.,)

RATIONALE: 

Physical Activity is a basic physiological need. If (patient name) cannot engage in physical activity while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy.

RELATED TO:

muscle weakness, tissue trauma (choose one)

OUTCOME: 

ambulate to nurses’ station and back with a steady gait, ambulate to bathroom and back safely, ambulate to hallway with walker at 150 feet and return to bed with assistance (choose one) during my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Maintain CPM (continuous or passive motion) while in bed – 

 – RATIONALE: Maintaining the CPM will allow for muscle flexibility which will lead to an increase in physical mobility

2} Assist patient with use of walker when getting out of bed (OOB). 

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

3} Provide assistive device, walker.

 – RATIONALE: Without the use of a assistive device/walker, patient does not have the muscular endurance of balance to increase his/her physical mobility.

4} Assist patient to standing position maintaining proper alignment.

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

5} Provide Rest periods

 – RATIONALE: Providing rest periods will allow patient to gradually increase his/her physical mobility

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED BED MOBILITY”? Here are some examples:

1} In report it was noted that patient is unable to move in bed effectively

2} In the chart it was noted that patient verbalized feeling he couldn’t move up in bed and was always sliding down

3} In report it was noted that patient is unable to use side rails to move up or down in bed effectively

4} In report it was noted that patient states he doesn’t know how to use overhead trapeze to move effectively in bed.

RATIONALE: 

Bed Mobility is a basic physiological need. If (patient name) cannot engage in basic bed mobility while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy.

RELATED TO:

muscle weakness, tissue trauma, musculoskeletal impairment (choose one)

OUTCOME: 

Patient will able to perform basic bed mobility such as moving up in bed and repositioning during PCS after interventions implemented. 

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Discuss with the patient ways to move safely in bed.

 – RATIONALE: By discussing options with patient on the ways to move safely in bed will allow patient to be able to understand how to perform basic bed mobility actions such as moving up in bed and repositioning. 

2} Instruct patient to use overhead trapeze correctly (ONLY USE if the patient actually has a trapeze!)

– RATIONALE: By instructing patient to use overhead trapeze correctly it will allow patient to understand how to be able to perform basic bed mobility actions such as moving up in bed and repositioning through the use of trapeze.

3} Instruct patient to use side rails to assist patient to move up or down in bed

– RATIONALE: By instructing patient to use the bed side rails as an aide it will allow patient to understand how to be able to perform basic bed mobility actions such as moving up in bed and repositioning through.

4}Perform [passive/active] range of motion to [assigned extremity] (ONLY USE if you are ASSIGNED Range Of Motion!)

– RATIONALE: Performing [passive/active] range of motion will increase muscle flexibility, balance and strength which will lead to improved bed mobility

5} Encourage patient to use arms and legs to move up or down in bed

– RATIONALE: By encouraging patient to use his arms and legs to reposition himself in bed will allow greater bed mobility through emotional support and a positive mental aspect.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE AIRWAY CLEARANCE”? Here are some examples:

1} In report it was noted that patient has rhonchi to right upper lobes

2} In the chart it was noted that patients lung sounds are diminished to bilateral lower lobes

3} In report it was noted that patient is unable to have an effective cough

4} In report it was noted that patient stated, “It feels like I just can’t cough up anything from my lungs.”

RATIONALE: 

A patent airway is a basic physiological need. If (patient name) continues with these retained secretions THEN he/she is at risk for COMPLICATIONS such as atelectasis, pulmonary infections, pneumonia and an increased hospital stay.

RELATED TO:

immobility, retained secretions, excessive secretions (choose one)

OUTCOME: 

have clear breath sounds through- out posterior lung fields after respiratory hygiene interventions

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Instruct patient to forcibly cough after 3 deep breaths

 – RATIONALE: By coughing the patient may expel retained secretions

2} Assist patient to use Incentive Spirometer 5 repetitions.

– RATIONALE: Through the use of the Incentive Spirometer the patients secretions will loosed and promote improved oxygenation

3} Administer assigned antibiotic.

– RATIONALE: By administering the prescribed antibiotic the patients infection will clear up, leading to a reduction in retained secretions

4} Assist patient with deep breathing and coughing

– RATIONALE: By assisting the patient to cough the patient may expel retained secretions.

NOTE: You can’t use this with INSTRUCT patient to cough forcibly. I put this in to show you how easy it is to change the beginning word to make a new intervention.

5}  Position patient in a semi Fowler’s position

– RATIONALE: By positioning patient to a Semi-Folwers position will allow increased oxygenation and airflow to the lungs, leading to a reduction in retained secretions

6} Request pain medication for patient prior to having patient cough

– RATIONALE: By requesting pain medication, patient will have an increased ability to expand lungs leading to a greater amount of expelled lung secretions.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “ACTIVITY INTOLERANCE”? Here are some examples:

1} In report it was noted that patient states, “I’m always feeling tired.”

2} In report it was noted that patient unable to walk to nurses station without being fatigued

3} In the chart it was noted that patient unable to transfer to chair without verbal reports of exhaustion

4} In report it was noted that patient unable to complete range of motion exercises due to fatigue.

RATIONALE: 

A tolerance to Activities is a basic physiological need. If (patient name) cannot have a tolerance to these basic activities  while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy which could lead to a prolonged hospital stay

RELATED TO:

generalized weakness, impaired lung gas exchange (choose one)

OUTCOME: 

ambulate to nurses’ station and back with a steady gait, ambulate to bathroom and back without shortness of breath, ambulate to hallway with walker at 150 feet and return to bed without verbal reports of weakness (choose one) during my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Administer/Maintain oxygen at two liters per nasal cannula (if applicable)

 – RATIONALE: Administering / Maintaining oxygen will allow for an increase in oxygen levels which will lead to an increased ability to tolerate activity. 

2} Assist patient with use of walker when getting out of bed (OOB). 

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

3} Provide assistive device, walker.

 – RATIONALE: Without the use of a assistive device/walker, patient does not have the muscular endurance of balance to increase his/her physical mobility.

4} Assist patient to standing position maintaining proper alignment of hip joint.

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

5} Provide Rest periods before activity/transferring/ambulation, etc., (choose one)

 – RATIONALE: Providing rest periods will allow patient to gradually increase his/her physical mobility

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED GASTROINTESTINAL MOTILITY”? Here are some examples: (please note, depending on if patient has constipation/diarrhea or just hypo/hper-active bowel sounds, the assessment will be different). 

1} In report it was noted that patient has hypoactive bowel sounds

2} In report it was noted that patient has hyperactive bowel sounds

3} In the chart it was noted that patient has not had a bowel movement for 3 days

4} In report it was noted that patient stated he has had diarrhea for 2 days

RATIONALE: 

The adequate functioning of the gastrointestinal tract  is a basic physiological need. If (patient name) is unable to have anadequate functioning of the gastrointestinal tract THEN he/she is at risk for COMPLICATIONS such as nausea, vomiting, diarrhea, hypoalbuminenia, and dehydration  which will lead to a prolonged hospital stay.

RELATED TO:

gastroenteritis

OUTCOME: 

active bowel sounds in all 4 abdominal quadrants after nursing interventions, Patient will reestablish and maintain normal pattern of bowel functioning (choose one)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Ambulate patient to nurses and station back x1 (constipation)

 – RATIONALE: Ambulating patient will help stimulate the natural action of peristalsis, thus leading to a reduction in constipation

2} Administer colace to patient (if assigned – constipation)

 – RATIONALE: The mechanism of action of colace is to soften the stool by pulling water and fats from the body into the intestines. By softening stool, patient will be able to have a bowel movement

3} Encourage oral fluids intake ( constipation)

 – RATIONALE: By increasing oral fluids such as water, the patients stool will be softened and the natural activity of peristalsis will be stimulated. By softening stool, patient will be able to have a bowel movement

4} Administer Anti-diarrheal medication as prescribed (diarrhea)

 – RATIONALE: By administering anti-diarrheal medications will allow the activity of the patients bowel will slow allowing for adequate absorption of fluids and nutrients thereby decreasing bowel sounds from hyperactive to active.

5} Maintain restriction of solid foods (diarrhea)

 – RATIONALE: By restricting solid foods, this will allow for bowel rest and reduce intestinal workload which may lead to patient re-establishing a normal pattern of bowel function.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE TISSUE PERFUSION”? Here are some examples:

1} In report it was noted that patient has cold clammy bilateral lower extremities

2} In report it was noted that patient has cap refill greater than 3 seconds

3} In the chart it was noted that patients pulses to bilateral extremities are faint and weak

4} In report it was noted that patient states, “My feet are always cold and hurt.”

RATIONALE: 

Adequate tissue perfusion is a basic physiological need. If (patient name) doesn’t have adequate tissue perfusion to his/her (sites) THEN he/she is at risk for COMPLICATIONS such as pallor, decreased sensation to (sites) and tissue necrosis which will lead to an extended hospital stay.

RELATED TO:

atherosclerosis, hypovolemia,decreased cardiac output (choose one)

OUTCOME: 

capillary refill time less than 3 seconds to (sites), extremity (site) warm with absence of pallor and cyanosis, pulses to (sites) strong and palpable (choose one) by end of my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Position affected (extremity) to (position)

 – RATIONALE: Positioning the affected extremity will allow for an increase in blood flow which will lead to site being warm with absence of pallor and cyanosis

2} Keep (extremity) warm 

 – RATIONALE: Keeping the (extremity) warm will allow for expansion of the arteries and veins which will lead to an increase in perfusion

3} Provide exercise

 – RATIONALE: Providing exercise allows the heart muscle to contract at a higher rate. Thus, the increased volume of blood moves more rapidly through the arteries and veins of the body, boosting circulation.

4} Maintain/Apply sequential compression device or antiembolism stockings

– RATIONALE: By maintaining/applying sequential compression devices or antiembolism stockings it will compress the legs thereby decreasing the amount of blood and pressure in the veins which leads to an increase in circulation

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED COMFORT”? Here are some examples:

1} In report it was noted that patient rated his comfort level at a 3 on a comfort verbal scale of 0-10

2} In report it was noted that patient rated his comfort level a 2 on a scale of 1-4 on the Daisies comfort scale

3} In the chart it was noted that patient stated, “I feel really uncomfortable because of this incision to my abdomen.”

4} In report it was noted that patient was showing signs of discomfort such as grimacing and clenching fists during ambulation

RATIONALE: 

An acceptable level of comfort is a basic physiological need. If (patient name) does not meet his/her acceptable level of comfort THEN he/she is at risk for COMPLICATIONS such as failure to participate in the plan of care that can lead to decreased tissue perfusion, skin breakdown, and muscle atrophy

RELATED TO:

this could be ANYTHING that is causing the patient discomfort and is to numerous to list

OUTCOME: 

Patient will state a 5 or HIGHER on the VERBAL COMFORT SCALE. Patient will state a score of 3-4 on the DAISIES COMFORT SCALE (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Again, the possibilities are ENDLESS on what interventions can make a patient comfortable. 

QUICK TIP: Ask the PRIMARY NURSE AND THE PATIENT what makes him/her comfortable and you’ll have your interventions!

CLICK ON ONE OF THE NURSING DIAGNOSIS TABS ABOVE TO DISCOVER THE “2 MINUTE TEMPLATE”

(super easy!)

**PLEASE NOTE: There is a BIG difference between Impaired SKIN integrity and impaired TISSUE integrity**

Impaired SKIN Integrity only involves the UPPER layers of the skin (epidermis and dermis). This would be considered a Stage I or II Pressure Ulcer or Partial Thickness wound.

Impaired TISSUE Integrity involves deeper layers of the skin (subcutaneous, muscle and bone). This would be considered a Stage III or IV Pressure Ulcer or Full Thickness wound.

 

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED SKIN INTEGRITY”? Here are some examples:

1} In report it was noted that patient has a stage I pressure ulcer to his coccyx

2} In report it was noted that patients stage II pressure ulcer has erythema with slight sero-sanguinous drainage

3} In the chart it was noted that patients stage I pressure ulcer measures 2cm length x 2 cm width x 0 cm depth

4} In report it was noted that patient states, “this pressure ulcer to my backside is uncomfortable.”

RATIONALE: 

Intact Skin is a basic physiological need. If (patient name) continues to have further kin breakdown  THEN he/she is at risk for COMPLICATIONS such as wound infection, osteomyelitis, septicemia which will lead to a prolonged hospital stay.

RELATED TO:

frequent loose stools, pressure from bed surface (choose one)

OUTCOME: 

patient will have NO redness to (site) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} change diaper as soon as wet or soiled.

– RATIONALE: By changing diaper as soon as it is wet or soiled will stop skin from continuing to being macerated and further skin break down

2} apply A & D ointment with every diaper change.

– RATIONALE: Applying A & D ointment will provide a barrier to moisture and intact skin from further breakdown

3} Change patients position every hour to offload pressure of ________

– RATIONALE: By offloading pressure points every hour will allow for a reduction in necrosis of tissue related to pressure which will prevent further skin breakdown.

**PLEASE NOTE: There is a BIG difference between Impaired SKIN integrity and impaired TISSUE integrity**

Impaired SKIN Integrity only involves the UPPER layers of the skin (epidermis and dermis). This would be considered a Stage I or II Pressure Ulcer or Partial Thickness wound.

Impaired TISSUE Integrity involves deeper layers of the skin (subcutaneous, muscle and bone). This would be considered a Stage III or IV Pressure Ulcer or Full Thickness wound.

 

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED TISSUE INTEGRITY”? Here are some examples:

1} In report it was noted that patient has a stage III pressure ulcer to his coccyx

2} In report it was noted that patients stage IV pressure ulcer is beefy red with bone exposed.

3} In the chart it was noted that patients stage III pressure ulcer measures 6cm length x 4 cm width x 4 cm depth

4} In report it was noted that patient states, “this wound to my backside is uncomfortable.”

RATIONALE: 

Intact Skin is a basic physiological need. If (patient name) continues to have skin breakdown or skin does not close  THEN he/she is at risk for COMPLICATIONS such as wound infection, osteomyelitis, septicemia which will lead to a prolonged hospital stay.

RELATED TO:

frequent loose stools, pressure from bed surface, trauma (choose one)

OUTCOME: 

patient will have a reduction of wound size dimensions at (site of wound like the coccyx or right heel or whatever) from current measurements of ___ x ___ x ___ (2cm x 2cm x 1cm) to ___ x ___ x ___ (2cm x 1cm x 0.5cm)  after interventions or at end of PCS (whichever is relevant)

OR

patient will have NO DRAINAGE to (site of wound like the coccyx or right heel or whatever) after interventions or at end of PCS (whichever is relevant)

OR

patient will have NO ODOR to (site of wound like the coccyx or right heel or whatever) after interventions or at end of PCS (whichever is relevant)

NURSING INTERVENTIONS & RATIONALE:

1} Perform wound care of (wound care orders).

– RATIONALE: By performing scheduled wound care to (site) patients bio-burden and bacterial load should decrease leading to wound size reduction and then closure.

2} change diaper as soon as wet or soiled.

– RATIONALE: By changing diaper as soon as it is wet or soiled will stop skin from continuing to being macerated and further skin break down

3} apply A & D ointment with every diaper change to surrounding skin.

– RATIONALE: Applying A & D ointment will provide a barrier to moisture and intact skin from further breakdown

4} Change patients position every hour to offload pressure of ________

– RATIONALE: By offloading pressure points every hour will allow for a reduction in necrosis of tissue related to pressure which will prevent further skin breakdown.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “ANXIETY”? Here are some examples:

1} In report it was noted that patient states, “I’m feeling anxious about surgery tomorrow.”

2} In report it was noted that patient has been irritable and restless

3} In the chart it was noted that patient unable to focus on simple instructions

4} In report it was noted that patient complains of tachycardia when talking about her cancer diagnosis

RATIONALE: 

Freedom of anxiety is a basic psychosocial need. If (patient name) continues to display increased anxiety THEN he/she is at risk for COMPLICATIONS such as headaches, insomnia, loss of appetite and depression.

RELATED TO:

change in health status, change in environment (choose one)

OUTCOME: 

Patient will verbalize no anxiety after interventions OR Patient will verbalize no anxiety by end of PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Explain all procedures and treatments to both patient and his parents.

 – RATIONALE: By explaining all procedures and treatments will allow patient to comprehend what is happening to her/him and will lead to a reduction in anxiety levels

2}Provide distraction activity of_____

 – RATIONALE: By distracting (patient name) with (distraction) it will allow the cognitive function process to reduce thought pattern of (whatever is causing patient anxiety) and will lead to reduced anxiety level.

Example: By distracting (Rob) with (TV) it will allow the cognitive function process to reduce thought pattern of (tomorrows appendectomy surgery) and will lead to reduced anxiety level.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “DEFICIENT FLUID VOLUME”? Here are some examples:

1} In report it was noted that patient states, “I feel dizzy and lightheaded”

2} In report it was noted that patients vital signs showed hypotension of 88/52

3} In the chart it was noted that patients skin turgor has been sluggish and oral mucosa has been dry

4} In report it was noted that infant patient has a depressed fontanelle

RATIONALE: 

Adequate fluid volume is a basic physiological need. If (patient name) cannot maintain/achieve adequate fluid volume THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion, hypotension and death. (OK, death is a little severe, but it could happen if you have a very sick patient)

RELATED TO:

diarrhea, blood loss, active fluid loss (choose one)

OUTCOME: 

Maintain elastic skin turgor; moist mucous membranes, flat fontanelle – Achieve elastic skin turgor; moist mucous membranes, flat fontanelle (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} administer IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour (or whatever is ordered)

 – RATIONALE: Administering IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour will allow for an increase in vascular hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

2} Encourage Fluids throughout PCS

 – RATIONALE: Having (patient name) drink more fluids will allow for systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

3} encourage the mother to breast feed ad lib.

 – RATIONALE: Encouraging (patent name’s) mother to breast feed more will allow for an increase in systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE BREATHING PATTERN”? Here are some examples:

1} In report it was noted that patient states, “I can’t take a deep breath because it hurts.”

2} In report it was noted that patients breathing pattern is tachypneic

3} In the chart it was noted that patients breathing pattern was orthopnea/dyspnea/cheyne-stokes/kussmals (choose one)

4} In report it was noted that patient takes gasping breaths while in bed

RATIONALE: 

An effective breathing pattern is a basic physiological need. If (patient name) is unable to have a breathing pattern that is effective  THEN he/she is at risk for COMPLICATIONS such as atelectasis and delayed healing due to hypoxemia

RELATED TO:

anxiety, pain, obesity (choose one)

OUTCOME: 

demonstrate a deep, regular breathing pattern after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} encourage patient to splint incision when taking deep breaths

– RATIONALE: By splinting incision will allow patient to reduce pain level which will lead to a deep breathing pattern

2) Have Primary nurse medicate patient before respiratory hygiene activities

 – RATIONALE: By medicating patient with pain medicine before respiratory hygiene activities will decrease pain impulses that will allow patient to take deep, regular breaths and increase lung expansion

3} encourage patient to use incentive spirometer ×5 repetitions during PCS

– RATIONALE: Using an Incentive spirometer will allow for patient to open up smaller alveoli sacs and expand lungs to a greater extent which will lead to a deep, regular breathing pattern

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED GAS EXCHANGE”? Here are some examples:

1} In report it was noted that patient states, “I’m always feeling restless and sometimes can’t catch my breath.”

2} In report it was noted that patients oxygen saturation ON ROOM AIR at 88% at times

3} In the chart it was noted that patients oxygen saturation ON SUPPLEMENTAL OXYGEN at 95% (remember, this patient is on supplemental oxygen because without it they would de-sat due to impaired gas exchange)

4} In report it was noted that patient has tachypnea/dyspnea

RATIONALE: 

Adequate gas exchange is a basic physiological need. If (patient name) doesn’t maintain an adequate oxygen exchange THEN he/she is at risk for COMPLICATIONS such as hypoxemia, tissue necrosis, tachycardia and respiratory failure.

RELATED TO:

COPD, pneumonia, respiratory infection (choose one)

OUTCOME: 

Patient will maintain 02 sats of 95% or greater during PCS.Patient will maintain 02 sats of __% or greater during PCS.  (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Maintain/Administer oxygen at __ liters per nasal cannula as needed

– RATIONALE: By maintaining supplemental oxygen at __ liters will not allow patient to experience hypoxemia, thereby allowing for oxygen saturation to be at __% or greater

2} Instruct patient to breathe slowly and deeply

– RATIONALE: Having patient breathe deeply and slowly will allow expansion of lungs and a greater infusion of alveolar sacs to become infused with oxygen leading to oxygen saturation of __% or greater.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “DEFICIENT KNOWLEDGE”? Here are some examples:

1} In report it was noted that patient states, “I just don’t understand why you need to assess my abdomen.”

2} In report it was noted that patient refuses to perform Incentive Spirometry (i.e. maybe she won’t do the incentive spirometer because no one explained to her why it’s so important)

3} In the chart it was noted that patient unable to name indications for 3 of her 5 medications that she takes at home.

4} In report it was noted that patient requests information on ROM exercises she can do at home.

RATIONALE: 

Understanding of information is a psychological need. Adequately instruction puts the content into focus and ensures continuity. Patient involvement improves compliance with health regimen and reduces complications such as non-compliance and adverse events.

RELATED TO:

Lack of proper explanation of information, lack of interest by patient, lack of instruction given, patient cognitive limitation (choose one)

OUTCOME: 

Patient will verbalize 100% understanding of (topic) by end of my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1}1} Instruct patient on _________

RATIONALE: By instructing (patient name) on (topic), he/she will be able to understand importance of (topic) to ensure that non-compliance and a negative adverse event do not happen

2} Repeat instructions as necessary so that patient can obtain 100% understanding of material taught.

RATIONALE: By repeating instructions to  (patient name) on (topic), he/she will be able to fully understand importance of (topic) to ensure that non-compliance and a negative adverse event do not happen.

ADDITIONAL INFORMATION

ALL INFORMATION BELOW Can Be Also Found In Chapter 4: Nursing Care Plans

RECOMMENDED NURSING DIAGNOSIS BOOKS

NOTE: any book you choose MUST be NEW or only ONE edition old.

  • #1 pick - Mosby's Guide to Nursing Diagnosis by Gail Ludwig
  • Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales by Marilyn Doenges

BASIC OVERVIEW OF THE NURSING CARE PLAN

1) Let's begin this lesson with the basics - Here's the Plan Of Care in all it's confusing glory:

 

 

Seems super easy right?... (yeah right!)

Don't worry my friend. We are going to break it down together so it makes sense. What we really need to do FIRST is find out WHEN we use each section of the PLAN OF CARE.

If you don't FULLY understand what the difference is between the Planning/Implementation/Evaluation Phases then stop what you're doing and review the INTRODUCTION chapter which explains what these are and why they are important.

 

Let's break this down even further and take a look at the FIRST section for the PLANNING PHASE: 

IMPORTANT!!!: This PLANNING phase nursing care plan is written BEFORE you see the patient, so be SUPER attentive when you're getting report and ask a lot of questions!

Here's Another Way To Look At Your Care Plan To Make SURE It's Correct. (PERFECTION DIRECTION Tool)

 

"...But what happens when I have to change something, Rob?"

That's a great question and the answer is you simply tell the examiner that something won't work in your PLANNING phase care plan and you're going to change it.

EXAMPLE: Let's say you've got the same patient and you go in to the room and the patient tells you, "It hurts to cough...I just had surgery and it's hurting to take those long deep breaths and then cough"...You'd probably tell the guy, "No problem, sir! We will just use this pillow to help you splint when you cough. It'll make things much less painful AND you'll be getting healthier with each breath!

This is where you would also inform the examiner of the change to intervention and fill out the form like this:

 

HEY, you're doing great! Last step is the EVALUATION phase of the care plan...

EXAMPLE: Let's see what that looks like for this patient:

arrow

 

And let's not forget the VERY LAST PAGE of the plan of care which deals with TEAMWORK...

EXAMPLE: Let's see what that looks like for this patient:

If you have this as an AOC -----------------------Then consider this as a nursing diagnosis:

Abdominal Assessment -

Respiratory management -

Musculoskeletal  -

Comfort Management -

Oxygen management -

Skin Assessment / Wound -

Fluid Management -

Enteral Feeding -

Neurologic Assessment -

Peripheral Neurovascular Management -

Wound Management -

Impaired GastroIntestinal Motility, Constipation,

Ineffective airway clearance, Ineffective Breathing Pattern

Impaired Physical/Bed Mobility

Impaired comfort / anxiety

Activity Intolerance / impaired gas exchange

Impaired Skin/Tissue Integrity

Deficient Fluid Volume

Imbalanced Nutrition: Less than

Confusion, Impaired Memory, Anxiety

Ineffective Peripheral Tissue Perfusion

Impaired Skin Integrity / Impaired Tissue Integrity

RELATED FACTOR

The Related Factor (or Etiology) can never be a procedure, treatment, or person

However, the use of a medical diagnosis as the etiology is acceptable !!

REMEMBER

 

The Assessment finding collected during Implementation that validates the nursing diagnosis can NEVER be ONLY medical orders or treatments. 

Ex. Patient is on 2 liters of supplemental oxygen via Nasal cannula - FAIL

Ex. Patient has oxygen saturation of 96% on 2 liters of supplemental supplemental oxygen before interventions and 97% after interventions - PASS

PRO-TIP!

You'll want to memorize these 2 minute templates below. You don't have to memorize VERBATIM, but try for at least 70% memorization. The BEST way to do this is to WRITE 1 Care Plan from the 2 minute templates below EVERY DAY for 1-2 months.

By doing that, they'll be so ingrained into your memory you won't forget them for MONTHS even AFTER you pass your CPNE test!

2 Minute Templates

CLICK ON ONE OF THE NURSING DIAGNOSIS TABS ABOVE TO DISCOVER THE “2 MINUTE TEMPLATE”

(super easy!)

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED PHYSICAL MOBILITY”? Here are some examples:

1} In report it was noted that patient has weakness during ambulation

2} In report it was noted that patient verbalized feeling unsteadiness during ambulation

3} In the chart it was noted that patient has an unsteady gait during ambulation

4} In report it was noted that patient unable to ambulate without assistive device (cane, walker, nurse, etc.,)

RATIONALE: 

Physical Activity is a basic physiological need. If (patient name) cannot engage in physical activity while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy.

RELATED TO:

muscle weakness, tissue trauma (choose one)

OUTCOME: 

ambulate to nurses’ station and back with a steady gait, ambulate to bathroom and back safely, ambulate to hallway with walker at 150 feet and return to bed with assistance (choose one) during my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Maintain CPM (continuous or passive motion) while in bed – 

 – RATIONALE: Maintaining the CPM will allow for muscle flexibility which will lead to an increase in physical mobility

2} Assist patient with use of walker when getting out of bed (OOB). 

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

3} Provide assistive device, walker.

 – RATIONALE: Without the use of a assistive device/walker, patient does not have the muscular endurance of balance to increase his/her physical mobility.

4} Assist patient to standing position maintaining proper alignment.

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

5} Provide Rest periods

 – RATIONALE: Providing rest periods will allow patient to gradually increase his/her physical mobility

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED BED MOBILITY”? Here are some examples:

1} In report it was noted that patient is unable to move in bed effectively

2} In the chart it was noted that patient verbalized feeling he couldn’t move up in bed and was always sliding down

3} In report it was noted that patient is unable to use side rails to move up or down in bed effectively

4} In report it was noted that patient states he doesn’t know how to use overhead trapeze to move effectively in bed.

RATIONALE: 

Bed Mobility is a basic physiological need. If (patient name) cannot engage in basic bed mobility while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy.

RELATED TO:

muscle weakness, tissue trauma, musculoskeletal impairment (choose one)

OUTCOME: 

Patient will able to perform basic bed mobility such as moving up in bed and repositioning during PCS after interventions implemented. 

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Discuss with the patient ways to move safely in bed.

 – RATIONALE: By discussing options with patient on the ways to move safely in bed will allow patient to be able to understand how to perform basic bed mobility actions such as moving up in bed and repositioning. 

2} Instruct patient to use overhead trapeze correctly (ONLY USE if the patient actually has a trapeze!)

– RATIONALE: By instructing patient to use overhead trapeze correctly it will allow patient to understand how to be able to perform basic bed mobility actions such as moving up in bed and repositioning through the use of trapeze.

3} Instruct patient to use side rails to assist patient to move up or down in bed

– RATIONALE: By instructing patient to use the bed side rails as an aide it will allow patient to understand how to be able to perform basic bed mobility actions such as moving up in bed and repositioning through.

4}Perform [passive/active] range of motion to [assigned extremity] (ONLY USE if you are ASSIGNED Range Of Motion!)

– RATIONALE: Performing [passive/active] range of motion will increase muscle flexibility, balance and strength which will lead to improved bed mobility

5} Encourage patient to use arms and legs to move up or down in bed

– RATIONALE: By encouraging patient to use his arms and legs to reposition himself in bed will allow greater bed mobility through emotional support and a positive mental aspect.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE AIRWAY CLEARANCE”? Here are some examples:

1} In report it was noted that patient has rhonchi to right upper lobes

2} In the chart it was noted that patients lung sounds are diminished to bilateral lower lobes

3} In report it was noted that patient is unable to have an effective cough

4} In report it was noted that patient stated, “It feels like I just can’t cough up anything from my lungs.”

RATIONALE: 

A patent airway is a basic physiological need. If (patient name) continues with these retained secretions THEN he/she is at risk for COMPLICATIONS such as atelectasis, pulmonary infections, pneumonia and an increased hospital stay.

RELATED TO:

immobility, retained secretions, excessive secretions (choose one)

OUTCOME: 

have clear breath sounds through- out posterior lung fields after respiratory hygiene interventions

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Instruct patient to forcibly cough after 3 deep breaths

 – RATIONALE: By coughing the patient may expel retained secretions

2} Assist patient to use Incentive Spirometer 5 repetitions.

– RATIONALE: Through the use of the Incentive Spirometer the patients secretions will loosed and promote improved oxygenation

3} Administer assigned antibiotic.

– RATIONALE: By administering the prescribed antibiotic the patients infection will clear up, leading to a reduction in retained secretions

4} Assist patient with deep breathing and coughing

– RATIONALE: By assisting the patient to cough the patient may expel retained secretions.

NOTE: You can’t use this with INSTRUCT patient to cough forcibly. I put this in to show you how easy it is to change the beginning word to make a new intervention.

5}  Position patient in a semi Fowler’s position

– RATIONALE: By positioning patient to a Semi-Folwers position will allow increased oxygenation and airflow to the lungs, leading to a reduction in retained secretions

6} Request pain medication for patient prior to having patient cough

– RATIONALE: By requesting pain medication, patient will have an increased ability to expand lungs leading to a greater amount of expelled lung secretions.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “ACTIVITY INTOLERANCE”? Here are some examples:

1} In report it was noted that patient states, “I’m always feeling tired.”

2} In report it was noted that patient unable to walk to nurses station without being fatigued

3} In the chart it was noted that patient unable to transfer to chair without verbal reports of exhaustion

4} In report it was noted that patient unable to complete range of motion exercises due to fatigue.

RATIONALE: 

A tolerance to Activities is a basic physiological need. If (patient name) cannot have a tolerance to these basic activities  while in hospital THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion and muscle atrophy which could lead to a prolonged hospital stay

RELATED TO:

generalized weakness, impaired lung gas exchange (choose one)

OUTCOME: 

ambulate to nurses’ station and back with a steady gait, ambulate to bathroom and back without shortness of breath, ambulate to hallway with walker at 150 feet and return to bed without verbal reports of weakness (choose one) during my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Administer/Maintain oxygen at two liters per nasal cannula (if applicable)

 – RATIONALE: Administering / Maintaining oxygen will allow for an increase in oxygen levels which will lead to an increased ability to tolerate activity. 

2} Assist patient with use of walker when getting out of bed (OOB). 

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

3} Provide assistive device, walker.

 – RATIONALE: Without the use of a assistive device/walker, patient does not have the muscular endurance of balance to increase his/her physical mobility.

4} Assist patient to standing position maintaining proper alignment of hip joint.

 – RATIONALE: Assisting patient will allow patient to increase endurance and may allow him/her to move past any hinderances of physical mobility

5} Provide Rest periods before activity/transferring/ambulation, etc., (choose one)

 – RATIONALE: Providing rest periods will allow patient to gradually increase his/her physical mobility

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED GASTROINTESTINAL MOTILITY”? Here are some examples: (please note, depending on if patient has constipation/diarrhea or just hypo/hper-active bowel sounds, the assessment will be different). 

1} In report it was noted that patient has hypoactive bowel sounds

2} In report it was noted that patient has hyperactive bowel sounds

3} In the chart it was noted that patient has not had a bowel movement for 3 days

4} In report it was noted that patient stated he has had diarrhea for 2 days

RATIONALE: 

The adequate functioning of the gastrointestinal tract  is a basic physiological need. If (patient name) is unable to have anadequate functioning of the gastrointestinal tract THEN he/she is at risk for COMPLICATIONS such as nausea, vomiting, diarrhea, hypoalbuminenia, and dehydration  which will lead to a prolonged hospital stay.

RELATED TO:

gastroenteritis

OUTCOME: 

active bowel sounds in all 4 abdominal quadrants after nursing interventions, Patient will reestablish and maintain normal pattern of bowel functioning (choose one)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Ambulate patient to nurses and station back x1 (constipation)

 – RATIONALE: Ambulating patient will help stimulate the natural action of peristalsis, thus leading to a reduction in constipation

2} Administer colace to patient (if assigned – constipation)

 – RATIONALE: The mechanism of action of colace is to soften the stool by pulling water and fats from the body into the intestines. By softening stool, patient will be able to have a bowel movement

3} Encourage oral fluids intake ( constipation)

 – RATIONALE: By increasing oral fluids such as water, the patients stool will be softened and the natural activity of peristalsis will be stimulated. By softening stool, patient will be able to have a bowel movement

4} Administer Anti-diarrheal medication as prescribed (diarrhea)

 – RATIONALE: By administering anti-diarrheal medications will allow the activity of the patients bowel will slow allowing for adequate absorption of fluids and nutrients thereby decreasing bowel sounds from hyperactive to active.

5} Maintain restriction of solid foods (diarrhea)

 – RATIONALE: By restricting solid foods, this will allow for bowel rest and reduce intestinal workload which may lead to patient re-establishing a normal pattern of bowel function.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE TISSUE PERFUSION”? Here are some examples:

1} In report it was noted that patient has cold clammy bilateral lower extremities

2} In report it was noted that patient has cap refill greater than 3 seconds

3} In the chart it was noted that patients pulses to bilateral extremities are faint and weak

4} In report it was noted that patient states, “My feet are always cold and hurt.”

RATIONALE: 

Adequate tissue perfusion is a basic physiological need. If (patient name) doesn’t have adequate tissue perfusion to his/her (sites) THEN he/she is at risk for COMPLICATIONS such as pallor, decreased sensation to (sites) and tissue necrosis which will lead to an extended hospital stay.

RELATED TO:

atherosclerosis, hypovolemia,decreased cardiac output (choose one)

OUTCOME: 

capillary refill time less than 3 seconds to (sites), extremity (site) warm with absence of pallor and cyanosis, pulses to (sites) strong and palpable (choose one) by end of my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Position affected (extremity) to (position)

 – RATIONALE: Positioning the affected extremity will allow for an increase in blood flow which will lead to site being warm with absence of pallor and cyanosis

2} Keep (extremity) warm 

 – RATIONALE: Keeping the (extremity) warm will allow for expansion of the arteries and veins which will lead to an increase in perfusion

3} Provide exercise

 – RATIONALE: Providing exercise allows the heart muscle to contract at a higher rate. Thus, the increased volume of blood moves more rapidly through the arteries and veins of the body, boosting circulation.

4} Maintain/Apply sequential compression device or antiembolism stockings

– RATIONALE: By maintaining/applying sequential compression devices or antiembolism stockings it will compress the legs thereby decreasing the amount of blood and pressure in the veins which leads to an increase in circulation

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED COMFORT”? Here are some examples:

1} In report it was noted that patient rated his comfort level at a 3 on a comfort verbal scale of 0-10

2} In report it was noted that patient rated his comfort level a 2 on a scale of 1-4 on the Daisies comfort scale

3} In the chart it was noted that patient stated, “I feel really uncomfortable because of this incision to my abdomen.”

4} In report it was noted that patient was showing signs of discomfort such as grimacing and clenching fists during ambulation

RATIONALE: 

An acceptable level of comfort is a basic physiological need. If (patient name) does not meet his/her acceptable level of comfort THEN he/she is at risk for COMPLICATIONS such as failure to participate in the plan of care that can lead to decreased tissue perfusion, skin breakdown, and muscle atrophy

RELATED TO:

this could be ANYTHING that is causing the patient discomfort and is to numerous to list

OUTCOME: 

Patient will state a 5 or HIGHER on the VERBAL COMFORT SCALE. Patient will state a score of 3-4 on the DAISIES COMFORT SCALE (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Again, the possibilities are ENDLESS on what interventions can make a patient comfortable. 

QUICK TIP: Ask the PRIMARY NURSE AND THE PATIENT what makes him/her comfortable and you’ll have your interventions!

CLICK ON ONE OF THE NURSING DIAGNOSIS TABS ABOVE TO DISCOVER THE “2 MINUTE TEMPLATE”

(super easy!)

**PLEASE NOTE: There is a BIG difference between Impaired SKIN integrity and impaired TISSUE integrity**

Impaired SKIN Integrity only involves the UPPER layers of the skin (epidermis and dermis). This would be considered a Stage I or II Pressure Ulcer or Partial Thickness wound.

Impaired TISSUE Integrity involves deeper layers of the skin (subcutaneous, muscle and bone). This would be considered a Stage III or IV Pressure Ulcer or Full Thickness wound.

 

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED SKIN INTEGRITY”? Here are some examples:

1} In report it was noted that patient has a stage I pressure ulcer to his coccyx

2} In report it was noted that patients stage II pressure ulcer has erythema with slight sero-sanguinous drainage

3} In the chart it was noted that patients stage I pressure ulcer measures 2cm length x 2 cm width x 0 cm depth

4} In report it was noted that patient states, “this pressure ulcer to my backside is uncomfortable.”

RATIONALE: 

Intact Skin is a basic physiological need. If (patient name) continues to have further kin breakdown  THEN he/she is at risk for COMPLICATIONS such as wound infection, osteomyelitis, septicemia which will lead to a prolonged hospital stay.

RELATED TO:

frequent loose stools, pressure from bed surface (choose one)

OUTCOME: 

patient will have NO redness to (site) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} change diaper as soon as wet or soiled.

– RATIONALE: By changing diaper as soon as it is wet or soiled will stop skin from continuing to being macerated and further skin break down

2} apply A & D ointment with every diaper change.

– RATIONALE: Applying A & D ointment will provide a barrier to moisture and intact skin from further breakdown

3} Change patients position every hour to offload pressure of ________

– RATIONALE: By offloading pressure points every hour will allow for a reduction in necrosis of tissue related to pressure which will prevent further skin breakdown.

**PLEASE NOTE: There is a BIG difference between Impaired SKIN integrity and impaired TISSUE integrity**

Impaired SKIN Integrity only involves the UPPER layers of the skin (epidermis and dermis). This would be considered a Stage I or II Pressure Ulcer or Partial Thickness wound.

Impaired TISSUE Integrity involves deeper layers of the skin (subcutaneous, muscle and bone). This would be considered a Stage III or IV Pressure Ulcer or Full Thickness wound.

 

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED TISSUE INTEGRITY”? Here are some examples:

1} In report it was noted that patient has a stage III pressure ulcer to his coccyx

2} In report it was noted that patients stage IV pressure ulcer is beefy red with bone exposed.

3} In the chart it was noted that patients stage III pressure ulcer measures 6cm length x 4 cm width x 4 cm depth

4} In report it was noted that patient states, “this wound to my backside is uncomfortable.”

RATIONALE: 

Intact Skin is a basic physiological need. If (patient name) continues to have skin breakdown or skin does not close  THEN he/she is at risk for COMPLICATIONS such as wound infection, osteomyelitis, septicemia which will lead to a prolonged hospital stay.

RELATED TO:

frequent loose stools, pressure from bed surface, trauma (choose one)

OUTCOME: 

patient will have a reduction of wound size dimensions at (site of wound like the coccyx or right heel or whatever) from current measurements of ___ x ___ x ___ (2cm x 2cm x 1cm) to ___ x ___ x ___ (2cm x 1cm x 0.5cm)  after interventions or at end of PCS (whichever is relevant)

OR

patient will have NO DRAINAGE to (site of wound like the coccyx or right heel or whatever) after interventions or at end of PCS (whichever is relevant)

OR

patient will have NO ODOR to (site of wound like the coccyx or right heel or whatever) after interventions or at end of PCS (whichever is relevant)

NURSING INTERVENTIONS & RATIONALE:

1} Perform wound care of (wound care orders).

– RATIONALE: By performing scheduled wound care to (site) patients bio-burden and bacterial load should decrease leading to wound size reduction and then closure.

2} change diaper as soon as wet or soiled.

– RATIONALE: By changing diaper as soon as it is wet or soiled will stop skin from continuing to being macerated and further skin break down

3} apply A & D ointment with every diaper change to surrounding skin.

– RATIONALE: Applying A & D ointment will provide a barrier to moisture and intact skin from further breakdown

4} Change patients position every hour to offload pressure of ________

– RATIONALE: By offloading pressure points every hour will allow for a reduction in necrosis of tissue related to pressure which will prevent further skin breakdown.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “ANXIETY”? Here are some examples:

1} In report it was noted that patient states, “I’m feeling anxious about surgery tomorrow.”

2} In report it was noted that patient has been irritable and restless

3} In the chart it was noted that patient unable to focus on simple instructions

4} In report it was noted that patient complains of tachycardia when talking about her cancer diagnosis

RATIONALE: 

Freedom of anxiety is a basic psychosocial need. If (patient name) continues to display increased anxiety THEN he/she is at risk for COMPLICATIONS such as headaches, insomnia, loss of appetite and depression.

RELATED TO:

change in health status, change in environment (choose one)

OUTCOME: 

Patient will verbalize no anxiety after interventions OR Patient will verbalize no anxiety by end of PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Explain all procedures and treatments to both patient and his parents.

 – RATIONALE: By explaining all procedures and treatments will allow patient to comprehend what is happening to her/him and will lead to a reduction in anxiety levels

2}Provide distraction activity of_____

 – RATIONALE: By distracting (patient name) with (distraction) it will allow the cognitive function process to reduce thought pattern of (whatever is causing patient anxiety) and will lead to reduced anxiety level.

Example: By distracting (Rob) with (TV) it will allow the cognitive function process to reduce thought pattern of (tomorrows appendectomy surgery) and will lead to reduced anxiety level.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “DEFICIENT FLUID VOLUME”? Here are some examples:

1} In report it was noted that patient states, “I feel dizzy and lightheaded”

2} In report it was noted that patients vital signs showed hypotension of 88/52

3} In the chart it was noted that patients skin turgor has been sluggish and oral mucosa has been dry

4} In report it was noted that infant patient has a depressed fontanelle

RATIONALE: 

Adequate fluid volume is a basic physiological need. If (patient name) cannot maintain/achieve adequate fluid volume THEN he/she is at risk for COMPLICATIONS such as skin breakdown, decreased tissue perfusion, hypotension and death. (OK, death is a little severe, but it could happen if you have a very sick patient)

RELATED TO:

diarrhea, blood loss, active fluid loss (choose one)

OUTCOME: 

Maintain elastic skin turgor; moist mucous membranes, flat fontanelle – Achieve elastic skin turgor; moist mucous membranes, flat fontanelle (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} administer IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour (or whatever is ordered)

 – RATIONALE: Administering IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour will allow for an increase in vascular hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

2} Encourage Fluids throughout PCS

 – RATIONALE: Having (patient name) drink more fluids will allow for systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

3} encourage the mother to breast feed ad lib.

 – RATIONALE: Encouraging (patent name’s) mother to breast feed more will allow for an increase in systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “INEFFECTIVE BREATHING PATTERN”? Here are some examples:

1} In report it was noted that patient states, “I can’t take a deep breath because it hurts.”

2} In report it was noted that patients breathing pattern is tachypneic

3} In the chart it was noted that patients breathing pattern was orthopnea/dyspnea/cheyne-stokes/kussmals (choose one)

4} In report it was noted that patient takes gasping breaths while in bed

RATIONALE: 

An effective breathing pattern is a basic physiological need. If (patient name) is unable to have a breathing pattern that is effective  THEN he/she is at risk for COMPLICATIONS such as atelectasis and delayed healing due to hypoxemia

RELATED TO:

anxiety, pain, obesity (choose one)

OUTCOME: 

demonstrate a deep, regular breathing pattern after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} encourage patient to splint incision when taking deep breaths

– RATIONALE: By splinting incision will allow patient to reduce pain level which will lead to a deep breathing pattern

2) Have Primary nurse medicate patient before respiratory hygiene activities

 – RATIONALE: By medicating patient with pain medicine before respiratory hygiene activities will decrease pain impulses that will allow patient to take deep, regular breaths and increase lung expansion

3} encourage patient to use incentive spirometer ×5 repetitions during PCS

– RATIONALE: Using an Incentive spirometer will allow for patient to open up smaller alveoli sacs and expand lungs to a greater extent which will lead to a deep, regular breathing pattern

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “IMPAIRED GAS EXCHANGE”? Here are some examples:

1} In report it was noted that patient states, “I’m always feeling restless and sometimes can’t catch my breath.”

2} In report it was noted that patients oxygen saturation ON ROOM AIR at 88% at times

3} In the chart it was noted that patients oxygen saturation ON SUPPLEMENTAL OXYGEN at 95% (remember, this patient is on supplemental oxygen because without it they would de-sat due to impaired gas exchange)

4} In report it was noted that patient has tachypnea/dyspnea

RATIONALE: 

Adequate gas exchange is a basic physiological need. If (patient name) doesn’t maintain an adequate oxygen exchange THEN he/she is at risk for COMPLICATIONS such as hypoxemia, tissue necrosis, tachycardia and respiratory failure.

RELATED TO:

COPD, pneumonia, respiratory infection (choose one)

OUTCOME: 

Patient will maintain 02 sats of 95% or greater during PCS.Patient will maintain 02 sats of __% or greater during PCS.  (choose one) after interventions or at end of PCS (whichever is relevant)

 

 

NURSING INTERVENTIONS & RATIONALE:

1} Maintain/Administer oxygen at __ liters per nasal cannula as needed

– RATIONALE: By maintaining supplemental oxygen at __ liters will not allow patient to experience hypoxemia, thereby allowing for oxygen saturation to be at __% or greater

2} Instruct patient to breathe slowly and deeply

– RATIONALE: Having patient breathe deeply and slowly will allow expansion of lungs and a greater infusion of alveolar sacs to become infused with oxygen leading to oxygen saturation of __% or greater.

ASSESSMENT: 

What are 2 assessments (signs and symptoms) that YOU heard IN THE REPORT the examiner gave you or READ IN THE CHART that VERIFIES this patient has the NURSING DIAGNOSIS of, “DEFICIENT KNOWLEDGE”? Here are some examples:

1} In report it was noted that patient states, “I just don’t understand why you need to assess my abdomen.”

2} In report it was noted that patient refuses to perform Incentive Spirometry (i.e. maybe she won’t do the incentive spirometer because no one explained to her why it’s so important)

3} In the chart it was noted that patient unable to name indications for 3 of her 5 medications that she takes at home.

4} In report it was noted that patient requests information on ROM exercises she can do at home.

RATIONALE: 

Understanding of information is a psychological need. Adequately instruction puts the content into focus and ensures continuity. Patient involvement improves compliance with health regimen and reduces complications such as non-compliance and adverse events.

RELATED TO:

Lack of proper explanation of information, lack of interest by patient, lack of instruction given, patient cognitive limitation (choose one)

OUTCOME: 

Patient will verbalize 100% understanding of (topic) by end of my PCS

 

 

NURSING INTERVENTIONS & RATIONALE:

1}1} Instruct patient on _________

RATIONALE: By instructing (patient name) on (topic), he/she will be able to understand importance of (topic) to ensure that non-compliance and a negative adverse event do not happen

2} Repeat instructions as necessary so that patient can obtain 100% understanding of material taught.

RATIONALE: By repeating instructions to  (patient name) on (topic), he/she will be able to fully understand importance of (topic) to ensure that non-compliance and a negative adverse event do not happen.

ASSESSMENTS

Assessments are completely different and might begin with words like:

Auscultate

Observe

Inspect

Monitor

Weigh

** You CANNOT use assessments as interventions or you will FAIL! ** 

INTERVENTIONS

Interventions move the patient TOWARDS the Expected Outcome. Interventions might begin with words like:

Instruct

Encourage

Maintain

Administer

Provide

Assist

MONITOR is NOT acceptable for interventions as MONITORING something is an ASSESSMENT. There is a HUGE difference between MONITORING oxygen level  (assessment) and MAINTAINING an oxygen level  (doing an action)

RATIONALE FOR SELECTED NURSING DIAGNOSIS

Rationales are NOT included in Mosby's NCP book which is a real bummer. But just remember this to make it super simple:

Rationales: are one or two sentences explaining WHY the nursing diagnosis you chose is a priority and what are the consequences IF that priority is NOT FIXED

It’s common to use an PHYSIOLOGICAL NEED / IF/THEN type of explanation with what will be a consequence.

 

TEMPLATE 1:  ______ is a basic physiological need. IF  PATIENT NAME does not have a ________ then he/she is at risk for complications such as ______, ______ and _____ which can potentially lead to a prolonged hospital stay.

TEMPLATE 2:  ______ is a basic physiological need. IF  PATIENT NAME does not have a ________ then he/she may be unable to fully participate in the Plan Of Care and is at risk for complications such as ______, ______ and _____ which can potentially lead to a prolonged hospital stay.

TEMPLATE #3: Promoting a _______ will help the patient to heal and prevent complications such as _______

 

 

For Ineffective airway clearance we would use:

A patent airway is a physiological need, IF the patient does not have a patent airway THEN he/she is at risk for complications such as respiratory distress and pneumonia, which can lead to an increased hospital stay.

Promoting a clear airway will assist patient to heal and prevent complications such as pneumonia

For Mobility we would use:

Mobility is a basic physical need, IF the patient does not have adequate mobility THEN he/she is at risk for skin breakdown, respiratory dysfunction and lack of willingness to participate in care, which can lead to an increased risk of pneumonia and prolonged hospital stay.

Promoting mobility will assist the patient to heal and prevent complications such as muscular atrophy.

I think you get the idea here.