NURSING CARE PLAN; MASTER GUIDE PRIOTISED

 

 NURSING CARE PROBLEMS

 (PRIORITISED)

BY PROF JONES H.M

1.     Impaired breathing patterns (dyspnea)

2.     Altered body temperature above normal (fever/hyperthermia)

3.     Altered body temperature below normal (hypothermia)

4.     Altered body fluid and electrolyte balance above body requirements(edema/fluid retention)

5.     Altered body fluid and electrolyte balance below body requirements(dehydration)

6.     Altered body nutritional status below body requirements(malnutrition)

7.     Altered comfort due to headache (pain)

8.     Impaired verbal communication

9.     Impaired skin integrity

10.  Altered body image

11.  Risk of infection

12.  Knowledge deficit

13.  Self-care deficit

14.  Anxiety

 

NURSING PROBLEM	NURSING DIAGNOSIS	AIMS/GOALS/ OBJECTIVES	NURSING INTERVENTIONS AND RATIONALE	EVALUATION
Impaired breathing patterns	Impaired breathing patterns due to blocked airways as evidenced by wheezing	To restore normal breathing patterns in 1 hour of nursing interventions.	I will do the following but not limited to: 1.     Put the patient in fowler’s position to promote lung expansion 2.     Administer humidified oxygen to improve gaseous exchange 3.     Suction the nose and mouth to remove any secretions 4.     Teach patient breathing exercises to improve patient’s breathing 5.     Remove foreign bodies blocking the airway to clear the airway 6.     Administer prescribed Broncho-dilators to widen the airways 7.     Monitor respirations every hour in order to see the treatment progress 8.     Support patient’s arms with pillows to move them away from the chest and facilitate breathing.	-After 1 hour of my nursing interventions, normal breathing was restored as evidenced by absence of wheezing.
Altered body temperature above normal	Altered body temperature above normal due to inflammatory response to infection as evidenced by temperature reading 39°C	To reduce the raised body temperature to normal range within 1 hour of nursing interventions.	1.     Tepid sponge my patient to promote heat loss through evaporation 2.     Open nearby windows to promote free circulation of fresh air promote heat loss through convection 3.     Remove excess clothing or linen to cool the body temperature 4.     You can give a cold drink to reduce the body temperature. 5.     Administer prescribed antipyretic to reduce the fever 6.     Monitor temperature every 30 minutes to note progress
Altered body temperature below normal	Altered body temperature below normal due to impaired skin integrity as evidenced by temperature reading of 35°C	To raise the body to normal range within 1 hour of nursing intervention.	1.     Switch on heater to raise room temperature 2.     Close nearby windows to prevent heat loss through convection 3.     Give warm fluids to raise body temperature 4.     Provide extra linen to prevent body heat loss 5.     Don’t touch patient with cold hands to prevent heat loss through conduction 6.     Monitor temperature every 30 minutes to note progress
Fluid and electrolyte imbalance above body requirements	Altered body fluid and electrolyte balance above normal due to fluid retention as evidenced by edema.	To reduce body fluid volume and correct electrolyte balance within 3 hours of nursing interventions.	1.     Reduce fluid intake to reduce internal body fluids 2.     Catheterize a patient to promote rapid urine output 3.     Open and use a fluid balance chart for easy monitoring fluid output 4.     Restrict salt intake to prevent fluid retention 5.     Administer prescribed diuretics to promote urination 6.     Measure blood pressure to prevent cardiac arrest 7.     Handle edematous skin gently to prevent breakdown because the skin is fragile 8.
Fluid and electrolyte imbalance below body requirements	Altered body fluid and electrolyte balance below normal due to fluid loss through diarrhea and vomiting as evidenced by dry mucous membranes	To increase body fluid volume and correct electrolyte balance within 3 hours of nursing interventions.	1.     Assess the levels of dehydration to pick appropriate rehydration plan 2.     Encourage fluid intake to increase body fluid 3.     Cannulate patient for intravenous fluid administration 4.     Administer prescribed fluids to increase plasma volume and electrolytes 5.     Open a fluid balance chart for easy monitoring of fluid input and output
Altered body nutritional status below body requirements	Altered body nutritional status below normal due to anorexia as evidenced by poor hair texture and distribution	To improve the patient’s nutritional status within 24 hours of nursing interventions.	1.     Insert a nasogastric(feeding) tube for easy delivery of excess nutrients 2.     Provide appetizing meals to stimulate appetite 3.     Provide small frequent meals to maintain appetite 4.     Provide diet rich in carbohydrates for body energy 5.     Provide meals rich in vitamins to boost immunity 6.     Provide meals rich in proteins to replace worn-out tissues 7.     Provide oral toilet to keep the mouth clean and refreshed and promotes salivation there by improving appetite. 8.     Encourage patients relatives to bring food from home, as the hospital meals are usually far from appetizing.
Altered comfort due to headache	Altered comfort due to headache as evinced patient’s facial expression	To promote patient’s comfort within 2 hours of nursing interventions.	1.     Assess the level of pain for baseline data 2.     Provide appropriate diversional therapy e.g. a magazine to divert the patient’s attention from pain. 3.     Provide a quite environment to promote rest 4.     Give warm compresses to relieve pain 5.     Remove linen in contact with site of pain to avoid compression on the site of pain 6.     Administer prescribed analgesics for pain relief 7.     Apply ice pack on site of pain to reduce pain transmission
Impaired verbal communication	Impaired verbal communication due to the inserted tracheostomy tube as evidenced by patient producing words that cannot be understood	To improve communication styles within 5 hours of nursing interventions.	1.     Involve patient’s relatives in the provision of care to assist in communication 2.     Put patient’s items nearby for easy reachability 3.     Teach simple sign language for easy communication 4.     Provide pen and paper for patient to write their concerns 5.
Impaired skin integrity	Impaired skin integrity due to burns as evidenced by bleeding	To promote the healing process of the impaired skin within 48 hours of nursing interventions.	1.     Assess the degree of burns to choose appropriate care 2.     Advise the patient not to touch the wound to prevent infecting it. 3.     Clean the wound to prevent accumulation of microbes on the wound 4.     Dress the wound after cleaning to keep the wound moist for healing promotion 5.     Provide air ring to relieve tension on the wound 6.     Apply tropical antibiotics for prophylaxis
Altered body image	Altered body image due to amputated limb as evidenced by patient using crouches	To improve patient’s self-esteem levels within 24 hours of nursing interventions.	1.     Provide psychological care to improve self esteem 2.     Provide crouches and wheelchair for easy mobility 3.     Advise patient to buy artificial limb (prosthetic) for cosmetic purposes 4.     Introduce patient to physiotherapist for rehabilitation 5.
Risk of infection	Risk of infection due to exposed wound as evidenced by patient touching the wound	To protect patient from getting nosocomial infections throughout hospitalization.	1.     Practice aseptic techniques when caring for the patient to prevent infection 2.     Clean the wound to prevent accumulation of microbes on the wound 3.     Dress the wound after cleaning to keep the wound moist for healing promotion 4.     Open nearby windows to promote proper ventilation 5.     Ensure a clean environment to reduce the risk of infection 6.     Perform nail care to prevent harboring of microbes 7.     Advise the patient not to touch the wound to prevent infecting it. 8.     Clean surfaces with 0.5 chlorine to remove microbes
Knowledge deficit	Knowledge deficit due to traditional beliefs as evidenced by patient giving self-diagnosis	To impart knowledge in a patient within 1 hour of nursing interventions.	1.     Ask patient about their knowledge of their condition to increase self esteem 2.     Encourage patient to verbalize their concerns to allay anxiety 3.     Encourage patient to ask questions so that you know what the patient knows and doesn’t know 4.     Answer questions truthfully to avoid giving false hope 5.     Explain to the patient the condition including the causes, sign, symptoms and complications to impart knowledge
Self-care deficit	Self-care deficit due to immobility as evidenced by patient being bedridden	To improve self-care within 24 hours of nursing interventions.	1.     Perform bed bath to promote comfort 2.     Change positions 2-hourly to prevent pressure sore formation 3.     Insert catheter to prevent bed wetting 4.     Perform oral care to promote appetite 5.     Insert nasogastric tube for feeding
Anxiety	Anxiety due to lack of knowledge as evidenced by patient resisting nursing care	To alley patient’s anxiety within 1 hour of nursing interventions.	1.     Asses anxiety to know the cause/source of it 2.     Ask patient about their knowledge of their condition to increase self esteem 3.     Encourage patient to verbalize their concerns to allay anxiety 4.     Encourage patient to ask questions so that you know what the patient knows and doesn’t know 5.     Answer questions truthfully to avoid giving false hope 6.     Involve the family in the care to promote adherence 7.     Explain to the patient the condition including the causes, sign, symptoms and complications to impart knowledge 8.     Arrange a psychosocial counsellor to talk to the patient.
Risk of injuries			1.     Don’t leave patient alone 2.     Remove excess furniture to prevent stumbling into them 3.     Make sure the floor is not slippery 4.     Raise the bed rails 5.     Make sure the room is well lit