Truth be told, care plans are the most disliked assignments in nursing school. If you think that you will squirm yourself out of it for some reason then you’re in for a rude shock. They are a mandatory assignment for every class; mental health, intensive care patients, community care. If this crucial paper has been assigned to you, be prepared to stay up all night trying to make sense of the scanty information sources and little time given. Remember, finishing the assignment in time is only half the battle because it needs to make sense if a worthy grade is to be awarded.
Why You Need Help with a Nursing Care Plan
Nursing Care Plan Sample
Clinical Assessment
Clinical assessment is undertaken in clinical environment after gaining consent from the client or their representatives. Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines and followed organizational policies and procedures.
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Part – A
You are to conduct a holistic assessment using the health facilities documentation. You will be required to perform the clinical skills:
| Clinical assessment | Client 1 | Client 2 |
| Body mass Index
Integumentary Assessment | 20
Normal | 28
Normal |
| Blood glucose Measurement | 150 mg/dl | 290mg/dl |
| Blood pressure Measurement | 100/68 mmhg | 140/90 mmhg |
| Oxygen saturation level | 99% | 98% |
| Temperature
Pulse Respiration | 99.0 F
62/mt 22/mt | 98.6F
86/mt 38/mt |
| Urinalysis
Color Appearance Specific gravity Protein urine Glucose urine Blood urine Bilirubin urine RBC urine WBC urine PH Leukocytes Esterase urine | Normal and Less in measureStraw color
1.010 Negative Negative present Negative 0 10 8.4 Negative | NormalStraw color
1.017 Negative Negative Negative Negative 0 3 Negative |
| Mental status Examination
Observation Appearance Speech Eye contact Motor activity Mood Cognition Orientation impairment Memory impairment Attention Perception Hallucination Thoughts Suicidailly Homicidally Delusions Behavior Insight Judgment | Neat
Normal Normal Normal Depressed None None Normal None None None None Co-operative Good Good | Neat
Normal Normal Normal Irritable None None Normal None None None None Co-operative Good Good |
| Neurological observation including reflexes
Open eyes Verbal response Motor respons | Spontaneously
Oriented Normal | Spontaneously
Oriented Normal |
| Neurovascular observation
And assessment of peripheral saturation Color Temperature Capillary refill Swelling Pulse | Pink
Cold 1 – 2 seconds No Normal | Pale
Warm >2 seconds Mild Normal |
| Pain assessment (including chest pain)
Pain Face Legs Activity Cry Console ability Chest pain assessing factors Provoking factors ,quality of pain ,radiation, severity, duration, timing, when pain Started, duration, location, characteristics, Aggregating factors. | Occasional expression of pain
Relaxed Moves easily Occasional complaints of abdominal pain Relaxed No complaints of chest pain | Smile
Relaxed Moves easily No cry Relaxed No complaints of chest pain |
Part – B
From your assessments you are to complete a nursing care plan for your client using the health facilities documentation. You must include nursing problems that you have assessed and at least two potential problems, nursing interventions, rationale for your nursing interventions and how you would evaluate your plan of care.
Client 1
Client 1 is admitted with the complaints of diarrhea, fever and abdominal pain for two day. Clinical assessment revels that client 1 is suffering from dehydration and pyrexia
| Assessment | Nursing diagnosis | Nursing intervention | Rationale | Evaluation |
| 1. Client is complaining of abdominal pain and he had six episodes of loose stools. | Diarrhea related to unhygienic practices. | 1. Assess and record the frequency, amount, color and characteristics of stool.
2. Restrict high fiber food. 3. Encourage and educate hygienic practices like hand washing. 4. administer anti-diarrheal and antibiotic as prescribed. | 1.It helps to assess the cause and plan the care for the client
2. High fiber foods worsen the condition. 3. Unhygienic practices may delay the client’s recovery and causes more complication. 4. Medications reduce the infection and promote the recovery. | After 12hours client is relaxed and had 2-3 episodes of loose stool. |
| 2. Client is febrile and complaints of head ache and body ache. | Increased in body temperature related to fluid lose. | 1. Assess vital signs every two hours.
2. Encourage the client take more fluids. 3. Administer antipyretic as per physicians order. | 1. Provides information about frequency, intensity and duration of fever.
2. Fluids maintains the body temperature 3. Reduces body temperature. | Clients body temperature reduced to 98.2F and no complaints of head ache and body ache. |
Client 2
Client 2 is admitted with the complaints of increased blood pressure and pedal edema for past three days.
| Assessment | Nursing diagnosis | Nursing intervention | Rationale | Evaluation |
| 1. Increased in blood pressure for about 140/90mmhg. | Increased blood pressure related to disease condition. | 1. Monitor clients’ blood pressure every 2 hours.
2. Advice to take low sodium diet. 3. Educate the client about limited fluid intake ordered by physician. 4. Administer anti -hypertensive as prescribed. | 1. It reveals the causative factors and helps to plan the nursing care.
2. Sodium increases the blood pressure. 3. Increase fluid will increase the blood volume. 4. Anti-hypertensive reduces blood pressure. | Blood pressure reduced to 126/82mmhg after 8 hours of nursing care. |
| 2. Clients both feet’s are swollen. | Pedal edema related to disease condition. | 1. Encourage the client to walk.
2. Provide extra pillows to elevate legs during rest. 3. Administer diuretics as per physicians order. 4. Encourage low sodium diet. | 1. Movement reduces the edema.
2. Elevation helps to push extra fluid towards heart. 3.Diuritics induces the Kidneys to eliminate extra fluid. 4. Sodium increases fluid intake which leads to increased blood volume. | Pedal edema reduced. |
Part – C
As part of your holistic patient care, you are required to participate in the planning and delivery of health teaching to your clients according to their health care needs. This may be required upon admission (i.e. for a procedure), when commencing new medications or prior to discharge.
Choose a client that you are caring for or have cared for in your clinical area. Select one dimension of their care that requires patient education.
- Identify the situation. Briefly describe why client education is required and what it is you are going to teach your client.
Client 1 admitted with the complaints of diarrhea and stomach pain. Client is losing fluid and electrolytes. Along with medical and nursing care, clients co-operation and awareness plays a key role in holistic health care. Client who is aware of his disease condition will contribute and support the healing process. I am planning to teach my client about complications of fluid and electrolyte loss, importance of fluid and electrolyte intake, awareness on unhygienic practices and its complications.
- Identify the steps you would take to plan and deliver your health teaching session. Remember to consider your Scope of Practice.
- Assess the need of the client
- Prioritize the care
- Set goals
- Develop pattern
- Implementation
- Evaluation
- How are you going to measure the learning outcomes?
Learning outcomes are measured by communicating to the client and evaluating the health teaching points.
- What delivery methods are you going to use?
Delivery methods used in health teaching are personal discussion, Group teaching, Group discussion, Demonstration, role play, Street play, audio-visual aids.
- Where are you going to deliver the session? What tools or props, if any,
Session will be delivered to the clients’ clinic. Tools used are Using posters and pictures, flannel board, chalk board, games, street play, role play, puppet show, audio-visual aids.
Would you use? Why would you use them?
Using tools and pros will improves the understanding of disease condition, its causes, treatment, complications and outcomes of the treatment. Health education with tools and pros will reach everybody in the community.
- Detail the content of your teaching session. (Include referencing).
My teaching session contains important factors of the disease condition like causes for disease, mode of transmission, incubation period, signs and symptoms, treatment and its complications.
Health teaching also contains the prevention of the disease or infection.
Identify community supports services that are available to the client
- Bali Lifetime Rehabilitation Support
- Reasonable pay for social and community services employees
- Strong and Resilient Communities
- Establishment of Communities
- Digital Learning for Elderly Australians Program
- Australian Government Certificate of Appreciation for Volunteers
- Economic Security and Ability.
- Emergency relief
- Commonwealth financial counseling
References
- rehydrate.org [1989]. A Supplement to Dialogue on Diarrhoea. Online issue : 39 Accessed From: http://www.rehydrate.org/dd/su39.htm Accessed on: 1989.
2.Department of Social Services. Australian Government [2017] Communities and Vulnerable People. Accessed From: https://www.dss.gov.au/our-responsibilities/communities-and-vulnerable-people/programs-services Accessed On: 20th December 2017
- Pereira Lima VL. Arruda JM, Barroso MA, Lobato Tavares MdE F. [2007].Analyzing the outcome of Health promotion practices., Accessed From: https://www.ncbi.nlm.nih.gov/pubmed/17596094 Accessed On: 2007
- Open Learn Create [2018] Health Education, Advocacy and Community Mobilisations. AccessedFrom:http://www.open.edu/openlearncreate/mod/oucontent/view.php?id=170§ion=1.6 AccessedOn:2018
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