Nursing Care Plan
Actual Nursing Diagnosis
Fatigue related to academic and work overload, working three 12 hour clinical shifts/week, taking an English evening course once/week, part-time job at Sport-Chek. Also, inadequate sleep, been up several nights writing a paper, excessive demands in her personal life, and spending time with the boyfriend.
Signs & Symptoms/Evidence:
1.) “Having difficulty maintaining her part-time job” 2.) “Having difficulty writing paper”
3.) “Finding it difficult to juggle all of these responsibilities and is feeling very anxious” Potential Nursing
Risk of Infection related to spent the previous afternoon with 2 of her peers, who called in sick the next day complaining of vomiting and diarrhea.
I chose fatigue as the priority nursing diagnosis because I feel that fatigue is the biggest concern for my client. Almost everything described by her relates to her fatigue: she is tried and overwhelmed with so many things happening in her life. With fatigue, energy and resources are depleted, remaining at an all-time low. This becomes the perfect gateway to lead onto other diseases processes such as mental illness, infections and metabolic disturbances (National Health Service, 2016). Fatigue is important to treat because it can affect the safety of herself and others around her. For instance, workplace and automobile accidents are likelier (Dept. of Health & Human Services, 2016). Her ability to perform sound patient care will also be compromised, putting the lives of those in her care under danger.
Write one outcome
statement that meets
the SMART criteria
All SMART criteria in one sentence
At the end of the three week period, my client will state that she has implemented three strategies to improve sleep and report sleeping from six to eight hours a night, at least five nights a week in her log.
Write one evaluation statement describing
At the end of the three week period, I will look over my client’s sleep log to examine progress and determine if the client-centered outcome has been met. I will also interview her and discuss the three sleep strategies she has how you plan to evaluate if the goal/outcome was met or not met.been asked to implement. During the interview, I will ask her how she feels emotionally and mentally, at work, school and home. This will give a good indication of her fatigue levels after remedying her sleep schedule.
interventions to meet
the goals set, and to
change or maintain
1) The nurse will
educate the client
regarding the benefits
of getting adequate
sleep and keeping a
2) The nurse will
educate and show the
client the basics
3) The nurse will
educate the client on
management of time
and stress. The client
will also be taught ways
to cope with stress.
Provide rationale for
selection of nursing
interventions and use
such as text, articles,
and internet sites to
support internet sites
to support choices
The client needs to
understand and value
sleep, otherwise she
has no incentive to
get the right amounts
of sleep. A sleep
journal is a good tool
to monitor one’s sleep
trends and is
invaluable if one
have been shown to
reduce tension and
invigorate the mind and
body, reducing fatigue
(Tang et al., 2007). It
also helps to prepare
one for sleep. Better
time is crucial to
reducing stress (Mills et
al, 2008). With stress,
and too much of it, it
can lead to anxiety, and
eventually fatigue if the
stress is prolonged and
excessive. If the client
can reduce the stress wants to improve their sleep (National
sleep equates to less
she experiences, her
fatigue would be less.
In the following discussion, we will examine the nursing process in detail, and discuss the importance of it in patient care. Next, we will consider how the metaparadigm concepts influenced the creation of my care plan. The SMART principle will be mentioned briefly, followed by a look at determinants of health that are applicable to my current client.
The Nursing process
The nursing process is a problem solving approach that applies nursing knowledge to practice. It consists of assessment, diagnosis, planning, implementation, and evaluation. The nursing process is widely accepted in healthcare as it allows for basic problem-solving processes to guide nursing decisions. (Potter & Perry, 2014).
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Assessment is important because vital information such as biological, sociocultural, environmental, spiritual and psychological data are obtained. This data will be used to form the client’s unique health or illness experience (Potter & Perry, 2014). Assessment helps us to formulate a baseline about the client’s needs and current health problems. It also aids us to identify the priority problems, which is the next step, so that we can create an appropriate intervention to promote the client’s health.
The diagnosis is a corollary to assessment. After organizing the data collected during assessment, the nurse can interpret major concerns and formulate a nursing diagnosis, which would direct the focus of patient care appropriately (Potter & Perry, 2014). It is extremely critical when formulating a nursing diagnosis, and especially a priority one, that all factors affecting the client’s health and wellness not be overlooked. The diagnosis will become the starting point for all interventions to promote the health of the client, identifying immediate needs, so the nurse must ensure that the diagnosis is appropriate and correct to the best of her ability.
Creating a plan of care involves setting priorities for the client, following the assessment and diagnosis. Planning is important because it outlines expected outcomes, and selects interventions that will resolve the client’s issues (Potter & Perry, 2014). By utilizing the SMART criteria, the nurse can then set specific goals and outcomes that are timely and measurable. Since this is the last step before actual implementation, the plan should be reviewed carefully to maximize patient safety.
After planning, interventions that are likely to achieve the goals and outcomes set earlier are put into action. In other words, intervention implementation is any treatment, based on clinical judgment and knowledge, to enhance the outcomes of the client (Potter & Perry, 2014).
Implementation involves a complex critical thinking approach because the nurse must ensure the interventions are appropriate for the clinical situation present. This can be done by examining all possible interventions, consequences, and effects associated with the particular approach.
The last step of the nursing process involves evaluating the outcome of the plan and the patient’s status. In this important step, success or failure is determined by whether or not the 8 NURSING CARE PLAN
intended outcomes have been achieved or not (Potter & Perry, 2014). If unsatisfactory, then perhaps the nursing interventions require some revision before continuing further. This process of evaluation is essentially a review that takes place after the intervention. It is then judged for improvement or progress based on the initial assessment and diagnosis.
The key bodies of knowledge that are necessary to understand a given clinical situation are collectively called the Metaparadigm concepts. The four concepts are client/person, health, environment/situation, and nursing.
Client or Person
Understanding the client or person, especially through different perspectives, such as a system of interacting parts, a system of competing human needs, or an entity with biological, psychological, social, and spiritual dimensions, helps us make the most comprehensive assessment we can, so we can provide the most optimal intervention for them (Potter & Perry, 2014). With a thorough assessment that includes all facets of the individual, a good nursing diagnosis can be made, resulting in a well thought-out comprehensive nursing plan. Knowing the individual on different levels allows me to make appropriate goals and outcomes that would benefit the client the most, as I can see what her best interests are.
Understanding that the client interacts with a complex set of environments is crucial to providing a solid nursing plan and care. The environments are varied and may include the 9 NURSING CARE PLAN
client’s family and social network, the community, and geopolitical issues that affect health (Potter & Perry, 2014). With this information, I am able to appreciate my client in a broader context, sort of as a whole, when planning for interventions. This allows for better and more suitable goal setting, meaning that outcomes will be more successful for my client as she is more receptive to the interventions.
The health concept is very important to proper assessment with the nursing process.
Viewing health as an ideal state of optimal health or total well-being which an individual can strive for is critical for both patient and nurse (Potter & Perry, 2014). With this in mind, I am able to collect pertinent data regarding the client’s state of health. It allows me to identify the positive practices she partakes to obtain wellness, as well as any negative practices that are detrimental to her well-being. It allows me to make a thorough and complete assessment of my client, which will ensure that nothing is missed so that a proper and appropriate nursing plan can be formulated.
The nursing concept has undergone different models, but it can generally be held as the nurse-client relationship, or a mutual relationship of the two, existing in a safe and caring environment (Dupree, 2017). This concept allows us to apply principles of knowledge, skills, technology, professional judgement and communication so that we can carry out our duties in achieving the best possible health outcome for our client. It allows us to be our best and helps develop rapport with our client. This nursing component enables us to integrate other metaparadigm concepts so that we can create timely and appropriate interventions as a whole.
SMART criteria allows us to make specific goals and outcomes, so that it can be precisely measured for our evaluation. They are client-centered, objective, observable and measureable (Potter & Perry, 2014). For my client, I was able to formulate a specific outcome that will improve her health, which is the reduction or elimination of fatigue by sleeping better. It was a realistic and attainable goal, meaning that my client will very likely follow through with the interventions. I took into account her busy schedule to give her decent amounts of time so that progress can be achieved and reviewed at the end. The SMART criteria makes goal setting very clear and exact, so that any other nurse can understand and take over my responsibilities if it comes to it.
Determinants of Health
According to Potter & Perry (2014), females tend to suffer from mental disorders more, such as depression and stress, then males. My client is clearly encumbered by financial constraints, work demands, school demands, and family demands. Knowing about this determinant of health allows me to identify better intervention strategies to offset this.
Personal Health Practices and Coping Skills
The client’s lack of proper nutrition, composed of coffee and take-out pizza for sustenance, will predispose her to major detrimental health consequences (Potter & Perry, 2014).
Her lack of coping skills to stress means she is more likely to suffer from stress and anxiety, and ultimately fatigue. This is why I have implemented an intervention that will educate her on time and stress management.
Social Support Networks
A strong social support network facilitates mental wellness and improves the rate of recovery (Potter & Perry, 2014). Good friends and family help alleviate stress and provide spiritual and psychological uplift. Unfortunately, my client is relatively new to the city, so most of her family are away, so they are unable to do this. This is important to know, because the nursing outcome, which is to reduce fatigue, will be partly hampered by her lack of social support..
Income and Social Status
Another aspect we should consider is a patient’s income and social status. Research has shown that those with better socioeconomic status have better health and quality of life as they have access to quality food, sound healthcare, and less stressors to worry about (Symbaluk & Bereska, 2016). As my client struggles financially, she is forced to work, meaning she has less time to focus on school, and becomes overwhelmed staying up late to finish assignments. This is a major contributor to the priority nursing diagnosis of fatigue.
Employment and working conditions
With clinical rotations of three 12 hour shifts a week, my client is constantly exposed to sources of infection. Being relatively new to a hospital environment, the body will take time to develop tolerances and resistances to infections, so she is likely to get sick more. This is reflected in the potential nursing diagnosis of risk of infection. The fact that she works at Sport-Chek too means she will only be more fatigued, reducing the effectiveness of her immune system even further.
As a nursing student, she should be very cognizant of the treatment plans and the importance of following through with it. She understands medical terminology and procedures, and will hopefully be a very compliant client. I have confidence in her knowing that she has a background in nursing and understands what she has to go through. The success of the intervention is greatly increased because of this determinant of health.
The client care plan is a complex piece of work that requires careful assessment and planning. We have to take into metaparadigm concepts when going through the nursing process.
Only then can we make a solid SMART outcome goal that will pave the way to better health for the client. Of course, we must also consider determinants of health as they vary considerably from person to person. Only then, can a suitable and effective care plan be established and carried out.
Department of Health & Human Services (2016). Fatigue. Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/fatigue Dupree, D. (2017) Four Basic Metaparadigm Concepts in Nursing. Retrieved from http://www.ehow.com/list_6106429_four-basic-metaparadigm-concepts-nursing.html Mills, H., Reiss, N., Dombeck, M. (2008). Time Management to Prevent Stress. Retrieved from https://www.mentalhelp.net/articles/time-management-to-prevent-stress/ National Health Service (2016). Why lack of sleep is bad for you. Retrieved from http://www.nhs.uk/Livewell/tiredness-and-fatigue/Pages/lack-of-sleep-health-risks.aspx National Sleep Foundation (2017). NSF Sleep Diary. Retrieved from https://sleepfoundation.org/sites/default/files/SleepDiaryv6.pdf Potter, P. A., & Perry, A. G. (2014). Canadian fundamentals of nursing (5th ed.). Toronto,
Onatrio: Mosby/Elsevier Canada.
Symbaluk, D. G., & Bereska, T. M. (2016). Sociology in Action: A Canadian Perspective, Second Edition. Toronto, Ontario: Nelson Education Ltd.
Tang, Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., Yu, Q., Sui, D., Rothbart, M., Fan, M., Posner, M. (2007). Short-term meditation training improves attention and self-regulation.
Proceedings of the National Academy of Sciences. 104, 43, 17152-6.
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