Nurses Zone | Source of Resources for Nurses

1. The purpose of a nursing care plan is to identify problems of a client and find solutions to the problems. This is done in five steps: assessment, diagnosis, planning, intervention, and evaluation. All five of these steps must be complete in order to have a true care plan.

2. Choose a priority nursing diagnosis approved by the North American Nursing Diagnosis Association (NANDA). Do not choose a potential nursing diagnosis first. The diagnosis column will include some assessment data. Ask yourself, “Why did I choose this particular diagnosis?” The answer should lie in the assessment data. Your diagnosis should read: nursing diagnosis… related to… as evidenced by…. The “as evidenced by” (AEB) should include your assessment data of how you decided on that particular diagnosis. The “related to” is the etiology or cause of the NANDA (and may be secondary to part of the medical diagnosis). The nursing diagnosis needs to be in Problem-Etiology-Supportive Data (PES) format.

3. The planning column is really a goal column. Here is where you put what you would like to see from the client by the end of your shift, clinical week or whatever your timeframe is. Goals address the NANDA. Goals should read “Client will…(turn around NANDA)… (time and measureable factors) AEB (outcome). The most important thing about your goals is that you must make them MEASURABLE. Use numbers where possible. Stay away from words like “a decrease in, an increase in, to look somewhat better, normal, etc.” Your evaluation should include exactly what the changes were. They should also be verifiable by someone else, so the nurses that read your nursing care plan know exactly what has been achieved in the plan of care. For example, if your client is in pain and rates his pain as an 8 on a scale of 1-10 and you want him, by the end of the day, to rate it as a 3. Or, client will walk around nurses’ station 3 times by the end of the shift. How many times? Three! This is a very measurable goal that another person could verify. Remember, measurable, measurable, and measurable!

4. Your interventions must be appropriate to help solve the etiology (cause of the NANDA). Remember that nursing care plan must be individualized and the sample care plan below is to serve as a guide. Others may be from your own imagination. As long as they will help your client to achieve his or her goals, they are worth doing!

5. You’ll need to include scientific rationale for each and every intervention. Rationales answer how and why you are doing the intervention with science and research. Be sure to number and line up your interventions to match your scientific rationale when you are writing them, so the nursing care plan is easy to understand.

6. The evaluation column will not be filled out until after you have completed your interventions. The question here is, “was my goal accomplished? Why or why not?” You may not always achieve your goals. That’s OK. If you didn’t, why not? Was the goal unrealistic for this client? Was the client out of the room most of the day? Did he just refuse your interventions? The lesson here is to learn what works best with different types of clients so that you can better take care of the next client down the line with the same problems. You are building something like a “database” in your head regarding nursing care. Sometimes, the same interventions won’t work on the same kinds of clients. Again, this is a learning experience for you.

7. One important thing to do in the mornings (or afternoons) when you are first talking to your client is to let them know what the plan of care for the day is going to be. This will be a much abbreviated version of your care plan. Let them know what you want to see them accomplish for the day and how together you can accomplish it.
Remember that even the best care plan is useless unless the client also believes in the same goals.

The awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function.

CLASS 1. Health Awareness
Recognition of normal function and well-being.

Diagnosis
– Deficient diversional activity
– Sedentary lifestyle

Class 2. Health management
Identifying, controlling, performing, and integrating activities to maintain health and well-being

Diagnosis
– Frail elderly syndrome
– Risk for frail elderly syndrome
– Deficient community health
– Risk-prone health behavior
– Ineffective health maintenance
– Ineffective health management
– Readiness for enhanced health management
– Ineffective family health management
– Noncompliance
– Ineffective protection

The activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue repair, and the production of energy.

Class 1. Ingestion
Taking food or nutrients into the body

Diagnosis
– Insufficient breast milk
– Ineffective breastfeeding
– Interrupted breastfeeding
– Readiness for enhanced breastfeeding
– Ineffective infant feeding pattern
– Imbalanced nutrition: less than body requirements
– Readiness for enhanced nutrition
– Obesity
– Overweight
– Risk for overweight
– Impaired swallowing

Class 2. Digestion
The physical and chemical activities that convert foodstuffs into Substances suitable for absorption and assimilation

Diagnosis
-None at present time

Class 3. Absorption
– The act of taking up nutrients through body tissues

Diagnosis
– None at present time

Class 4. Metabolism
The chemical and physical processes occurring in living organisms and cells for the development and use of protoplasm, the production of waste and energy, with the release of energy for all vital processes

Diagnosis
– Risk for unstable blood glucose level
– Neonatal jaundice
– Risk for neonatal jaundice
– Risk for impaired liver function

Class 5. Hydration
The taking in and absorption of fluids and electrolytes

Diagnosis
– Risk for electrolyte imbalance
– Readiness for enhanced fluid balance
– Deficient fluid volume
– Risk for deficient fluid volume
– Excess fluid volume
– Risk for imbalanced fluid volume

Secretion and excretion of waste product from the body

Class 1. Urinary function
The process of secretion, reabsorption, and excretion of urine

Diagnosis
– Impaired urinary elimination
– Readiness for enhanced urinary elimination
– Functional urinary incontinence
– Overflow urinary incontinence
– Reflex urinary incontinence
– Stress urinary incontinence
– Urge urinary incontinence
– Risk for urge urinary incontinence
– Urinary retention

Class 2. Gastrointestinal function
The process of absorption and excretion of the end products of digestion

Diagnosis
– Constipation
– Risk for constipation
– Chronic functional constipation
– Risk for chronic functional constipation
– Perceived constipation
– Diarrhea
– Dysfunctional gastrointestinal motility
– Risk for dysfunctional gastrointestinal motility
– Bowel incontinence

Class 3. Integumentary function
The process of secretion and excretion through the skin

Diagnosis
-None at this time

Class 4. Respiratory function
The process of exchange of gases and removal of the end products of metabolism

Diagnosis
– Impaired gas exchange

The production, conservation, expenditure, or balance of energy resources

Class 1. Sleep/Rest
Slumber, repose, ease, relaxation, or inactivity

Diagnosis
– Insomnia
– Sleep deprivation
– Readiness for enhanced sleep
– Disturbed sleep pattern

Class 2. Activity/Exercise
Moving parts of the body (mobility), doing work, or performing actions often (but not always) against resistance

Diagnosis
– Risk for disuse syndrome
– Impaired bed mobility
– Impaired physical mobility
– Impaired wheelchair mobility
– Impaired sitting
– Impaired standing

Diagnosis
– Impaired transfer ability
– Impaired walking

Class 3. Energy balance
A dynamic state of harmony between intake and expenditure of resources

Diagnosis
– Fatigue
– Wandering

Class 4. Cardiovascular/pulmonary responses
Cardiopulmonary mechanisms that support activity/rest

Diagnosis
– Activity intolerance
– Risk for activity intolerance
– Ineffective breathing pattern
– Decreased cardiac output
– Risk for decreased cardiac output
– Risk for impaired cardiovascular function
– Risk for ineffective gastrointestinal perfusion
– Risk for ineffective renal perfusion
– Impaired spontaneous ventilation
– Risk for decreased cardiac tissue perfusion
– Risk for ineffective cerebral tissue perfusion
– Ineffective peripheral tissue perfusion
– Risk for ineffective peripheral tissue perfusion
– Dysfunctional ventilatory weaning response

Class 5. Self-care
Ability to perform activities to care for one’s body and bodily functions

Diagnosis
Impaired home maintenance
– Bathing self-care deficit*
– Dressing self-care deficit*
– Feeding self-care deficit*
– Toileting selfself-care deficit*
– Readiness for enhanced self
– Self-neglect

The human information processing system including attention, orientation, sensation, perception, cognition and communication.

Class 1. Attention
Mental readiness to notice or observe

Diagnosis
– Unilateral neglect

Class 2. Orientation
Awareness of time, place, and person

Diagnosis
– None at this time

Class 3. Sensation/perception
Receiving information through the senses of touch, taste, smell, vision, hearing, and kinesthesia, and the comprehension of sensory data resulting in naming, associating, and/or pattern recognition

Diagnosis
– None at this time

Class 4. Cognition
Use of memory, learning, thinking, problem-solving, abstraction, judgment, insight, intellectual capacity, calculation, and language

Diagnosis
– Acute confusion
– Risk for acute confusion
– Chronic confusion
– Labile emotional control
– Ineffective impulse control
– Deficient knowledge
– Readiness for enhanced knowledge
– Impaired memory

Class 5. Communication
Sending and receiving verbal and nonverbal information

Diagnosis
– Readiness for enhanced communication
– Impaired verbal communication

Awareness about the self

Class 1. Self-concept
The perception(s) about the total self

Diagnosis
– Readiness for enhanced hope
– Hopelessness
– Risk for compromised human dignity
– Disturbed personal identity
– Risk for disturbed personal identity
– Readiness for enhanced self-concept

Class 2. Self-esteem
Assessment of one’s own worth, capability, significance, and success

Diagnosis
– Chronic low self-esteem
– Risk for chronic low self-esteem
– Situational low self-esteem
– Risk for situational low self-esteem

Class 3. Body image
A mental image of one’s own body

Diagnosis
-Disturbed body image

The positive and negative connections or associations between people or groups of people and the means by which those connections are demonstrated.

Class 1. Caregiving Roles
Socially expected behavior patterns by people providing care who are not healthcare professionals

Diagnosis
– Caregiver role strain
– Risk for caregiver role strain
– Impaired parenting
– Readiness for enhanced parenting
– Risk for impaired parenting

Class 2. Family Relationships
Associations of people who are biologically related or related by choice

Diagnosis Page
– Risk for impaired attachment
– Dysfunctional family processes
– Interrupted family processes
– Readiness for enhanced family processes

Class 3. Role Performance
Quality of functioning in socially expected behavior patterns

Diagnosis Page
– Ineffective relationship
– Readiness for enhanced relationship
– Risk for ineffective relationship
– Parental role conflict
– Ineffective role performance
– Impaired social interaction

Sexual identity, sexual function, and reproduction

Class 1. Sexual identity
The state of being a specific person in regard to sexuality and/or gender

Diagnosis
– None at present time

Class 2. Sexual function
The capacity or ability to participate in sexual activities

Diagnosis
– Sexual dysfunction
– Ineffective sexuality pattern

Class 3. Reproduction
Any process by which human beings are produced

Diagnosis
– Ineffective childbearing process
– Readiness for enhanced childbearing process
– Risk for ineffective childbearing process
– Risk for disturbed maternal–fetal dyad

Contending with life events/ life processes

Class 1. Post-trauma responses
Reactions occurring after physical or psychological trauma

Diagnosis
– Post-trauma syndrome
– Risk for post-trauma syndrome
– Rape-trauma syndrome
– Relocation stress syndrome
– Risk for relocation stress syndrome

Class 2. Coping responses
The process of managing environmental stress

Diagnosis
– Ineffective activity planning
– Risk for ineffective activity planning
– Anxiety
– Defensive coping
– Ineffective coping
– Readiness for enhanced coping
– Ineffective community coping
– Readiness for enhanced community coping
– Compromised family coping
– Disabled family coping
– Readiness for enhanced family coping
– Death anxiety
– Ineffective denial
– Fear
– Grieving
– Complicated grieving
– Risk for complicated grieving
– Impaired mood regulation
– Readiness for enhanced power
– Powerlessness
– Risk for powerlessness
– Impaired resilience
– Readiness for enhanced resilience
– Risk for impaired resilience
– Chronic sorrow
– Stress overload

Class 3. Neurobehavioral stress
Behavioral responses reflecting nerve and brain function

Diagnosis
– Decreased intracranial adaptive capacity
– Autonomic dysreflexia
– Risk for autonomic dysreflexia
– Disorganized infant behavior
– Readiness for enhanced organized infant behavior
– Risk for disorganized infant behavior

Principles underlying conduct, thought and behavior about acts, customs, or institutions viewed as being true or have intrinsic worth.

Class 1. Values
The identification and ranking of preferred modes of conduct or end states

Diagnosis
– None at this time

Class 2. Beliefs
Opinions, expectations, or judgments about acts, customs, or institutions viewed as being true or having intrinsic worth

Diagnosis
– Readiness for enhanced spiritual well-being

Class 3. Value/Belief/Action Congruence
The correspondence or balance achieved among values, beliefs, and actions

Diagnosis
– Readiness for enhanced decision-making
– Decisional conflict
– Impaired emancipated decision-making
– Readiness for enhanced emancipated
– Decision-making
– Risk for impaired emancipated decision-making
– Moral distress
– Impaired religiosity
– Readiness for enhanced religiosity
– Risk for impaired religiosity
– Spiritual distress
– Risk for spiritual distress

Freedom from danger, physical injury or immune system damage; preservation from loss; and protection of safety and security

Class 1. Infection
Host responses following pathogenic invasion

Diagnosis
-Risk for infection

Class 2. Physical injury
Bodily harm or hurt

Diagnosis
– Ineffective airway clearance
– Risk for aspiration
– Risk for bleeding
– Risk for dry eye
– Risk for falls
– Risk for injury*
– Risk for corneal injury*
– Risk for perioperative positioning injury*
– Risk for thermal injury*
– Risk for urinary tract injury*
– Impaired dentition
– Impaired oral mucous membrane
– Risk for impaired oral mucous membrane
– Risk for peripheral neurovascular dysfunction
– Risk for pressure ulcer
– Risk for shock
– Impaired skin integrity
– Risk for impaired skin integrity
– Risk for sudden infant death syndrome
– Risk for suffocation
– Delayed surgical recovery
– Risk for delayed surgical recovery
– Impaired tissue integrity
– Risk for impaired tissue integrity
– Risk for trauma
– Risk for vascular trauma

Class 3. Violence
The exertion of excessive force or power so as to cause injury or abuse

Diagnosis Page
– Risk for other-directed violence
– Risk for self-directed violence
– Self-mutilation
– Risk for self-mutilation
– Risk for suicide

Class 4. Environmental hazards
– Sources of danger in the surroundings

Diagnosis
– Contamination
– Risk for contamination
– Risk for poisoning

Class 5. Defensive processes
The processes by which the self protects itself from the nonself

Diagnosis
– Risk for adverse reaction to iodinated contrast media
– Risk for allergy response
– Latex allergy response
– Risk for latex allergy response

Class 6. Thermoregulation
The physiological process of regulating heat and energy within the body for purposes of protecting the organism

Diagnosis
– Risk for imbalanced body temperature
– Hyperthermia
– Hypothermia
– Risk for hypothermia
– Risk for perioperative hypothermia
– Ineffective thermoregulation

Sense of mental, physical, or social well-being or ease

Class 1. Physical comfort
Sense of well-being or ease and/or freedom from pain

Diagnosis
– Impaired comfort
– Readiness for enhanced comfort
– Nausea
– Acute pain
– Chronic pain
– Labor pain
– Chronic pain syndrome

Class 2. Environmental comfort
Sense of well-being or ease in/with one’s environment

Diagnosis
– Impaired comfort
– Readiness for enhanced comfort

Class 3. Social comfort
Sense of well-being or ease with one’s social situation

Diagnosis
– Impaired comfort
– Readiness for enhanced comfort
– Risk for loneliness
– Social isolation

Age-appropriate increase in physical dimensions, maturation of organ system and/or progression through the developmental milestones

Class 1. Growth
Increases in physical dimensions or maturity of organ systems

Diagnosis
-Risk for disproportionate growth

Class 2. Development
Progress or regression through a sequence of recognized milestones in life

Diagnosis
– Risk for delayed development