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Nursing Care Plan Writing

Nursing Care Plan Writing

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

A nursing care plan is meant to offer direction on the personalized care of a patient. It takes direction from the patient’s diagnosis and guided by their specific needs as far as treatment and recovery are concerned.
A care plan is a silent source of communication among different nurses regarding a particular patient. With each nurse updating it after attending to the patient, it is handed over to the nursing staff after every shift and in the middle of nursing rounds.
 
Nursing care plans facilitate documentation. They outline the kind of observations to make, the type of nursing action to carry out, and the type of instructions to give to the patient and their family. This vital document also serves a great deal in assigning nursing staff to the care of the patient. There are instances when a patient requires specific care that can only be given by nurses who have specific skills. Nursing care plans are also used as a guide for reimbursement. Therefore, a look at how important this project is puts even more pressure on the already overwhelmed nursing students. Through this, your professor will get to know whether you are ready for the real job and whether you are capable of applying your skills.
 
If you are feeling overwhelmed, take comfort in knowing that thousands of nursing students are going through the same thing. However, a chosen handful have discovered the secret; hiring a team of professionals to handle the project for them. Although there are many academic writing companies out there, only a chosen few are capable of delivering what is needed. In order to comprehend this, the writing company needs to have undergone a similar process.
 
At nursingwritinghelp.com we are skilled and qualified enough to handle such delicate projects with high level of professionalism. Some of our staff members are individuals who were professors in nursing schools while most writers are nursing graduates who excelled in their academics and choose to help fellow nursing students. In this case, we guarantee that the end result of your well-written nursing care plan paper will earn you a perfect grade.
 
Your academic success is important and that is why we go the extra mile to see to it that you submit a pleasant assignment paper. Additionally, we facilitate close monitoring of the paper whereby you can keep in touch with your preferred writer. This creates a familiar connection which gives the paper a custom feel to it. With us, every dream is a possibility!

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 assessmentClient 1Client 2
Body  mass Index

 

Integumentary Assessment

20

 

Normal

        28

 

Normal

Blood glucose Measurement150 mg/dl290mg/dl
Blood pressure Measurement100/68 mmhg140/90 mmhg
Oxygen saturation level99%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

AssessmentNursing diagnosisNursing interventionRationaleEvaluation
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.

AssessmentNursing diagnosisNursing interventionRationaleEvaluation 
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.

  1. 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.

  1. 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.

  1. 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

  1. 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

  1. 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
  2. Open Learn Create [2018] Health Education, Advocacy and Community Mobilisations. AccessedFrom:http://www.open.edu/openlearncreate/mod/oucontent/view.php?id=170&section=1.6 AccessedOn:2018
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