nursing care plan template

Write a nursing care plan on a patient diagnosed with dementia using nursing diagnosis. The rationale for the interventions should be evidence-based with recent peer-reviewed sources. Also please follow the attached instructions and guidelines and the NANDA diagnosis list assignment

Write 2 nursing care plan

How do you write a nursing care plan?

How to Proceed
• Connecting with patient X, compose and submit a Nursing Care Plan in relation to their individual needs using the template format below.
• Include one patient-specific, individualized nursing diagnosis (NANDA diagnosis). Each diagnosis should have one
one SMART goal, three interventions and three rationales for each intervention, and evaluation.
• The rationale for interventions should be appropriately cited evidence-based sources.

Nursing care plan format

Medical diagnosis: Dementia

Assessment

Nursing diagnosis

plan

intervention

rationale

evaluation

How do you write a simple nursing care plan?

nursing care plan template

Observations and interaction from the interview

Patient X is born wit

h a chromosomal abnormality and has impaired memory. He has never been married and the only family he can remember is his brother who he missed so much. He is happy in his environment and likes everyone, especially the staff. He likes the food mostly and doesn’t really know any game. Despite his impaired memory, he talks a lot about his brother who is late. He is quiet

Patient X medical diagnosis

Type 2 diabetes

Dementia

Parkinson

Chromosomal abnormality

Observations

Impaired speech,

Increased memory loss-forgets room number, cant operate a tv or radio anymore

Incontinent both day and night on both bladder and bowel requires supervision on both

Behaviours – wanders

Mobility is independent

Moderate impaired vision

Examples of Nursing Care Plan

nursing care plan template

Health Promotion

Health Awareness

Deficient diversional activity
Sedentary lifestyle

Health Management

Deficient community health
Risk-prone health behaviour
Ineffective health maintenance
Readiness for enhanced health maintenance
Readiness for enhanced immunization status
Ineffective protection
Ineffective self-health management
Readiness for enhanced self- health management
Ineffective family therapeutic regimen management

Nutrition

Ingestion

Insufficient breast milk
Ineffective infant feeding [pattern]
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: more than body requirements
Risk for imbalanced nutrition more than body requirements
Readiness for enhanced nutrition
Impaired swallowing

Gastrointestinal function

Constipation
Perceived constipation
Risk for constipation
Diarrhea
Dysfunctional gastrointestinal motility
Risk for Dysfunctional gastrointestinal motility
Bowel incontinence

Respiratory function

Impaired gas exchange Activity and rest

Sleep/Rest

Insomnia
Sleep deprivation
Readiness for enhanced sleep
Disturbed sleep pattern

Activity/Exercise

Risk for disuse syndrome
Impaired bed mobility
Impaired physical mobility
Impaired wheelchair mobility
Impaired transfer ability
Impaired walking

Energy balance

Disturbed energy field
Fatigue
Wandering

Cardiovascular/pulmonary responses

Activity intolerance
Risk for activity intolerance
Ineffective breathing pattern
Decreased cardiac output
Risk for ineffective gastrointestinal perfusion
Risk for ineffective renal perfusion
Impaired spontaneous ventilation
Ineffective peripheral tissue perfusion
Risk for decreased cardiac tissue perfusion
Risk for ineffective cerebral tissue perfusion
Risk for peripheral tissue perfusion
Dysfunctional ventilator weaning response

Self-care

Impaired home maintenance
Readiness for enhanced self-care

Bathing self-care deficit
Dressing self-care deficit
Feeding self-care deficit
Toileting self-care deficit
Self-neglect Perception/cognition Attention
Unilateral neglect

Orientation

Impaired environmental interpretation syndrome

Cognition

Acute confusion
Chronic confusion
Risk for acute confusion
Ineffective impulse control
Deficient knowledge
Readiness for enhanced knowledge
Impaired memory

Communication

Readiness foe enhanced communication
Impaired verbal communication Self-perception

Self-concept

Hopelessness
Risk for compromised human dignity
Risk for loneliness
Disturbed personal identity
Risk for disturbed personal identity
Readiness for enhanced self- concept

Self esteem

Chronic low self esteem
Risk for chronic low self esteem
Risk for situational low self esteem
Situational low self esteem

Body image

Disturbed body image Role relationships

Caregiving roles

Ineffefctive breastfeeding
Interrupted breast feeding
Readiness for enhanced breast feeding
Caregiver role strain
Risk for caregiver role strain
Impaired parenting
Readiness for enhanced parenting
Risk for impaired parenting

Family relationships

Risk for impaired attachment
Dysfunctional family process

Interrupted family processes
Readiness for enhanced family processes

Role performance

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

Sexuality

Sexual function

Sexual dysfunction
Ineffective sexual pattern

Reproduction

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

Coping/Stress tolerance

Post trauma responses

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

Coping responses

Ineffective activity planning
Risk for ineffective activity planning
Anxiety
Compromised family coping
Defensive coping
Disabled family coping
Ineffective coping
Ineffective community coping
Readiness for enhanced coping
Readiness for enhanced community coping
Readiness for enhanced family coping
Death anxiety
Ineffective denial
Adult failure to thrive
Fear
Grieving
Complicated grieving
Risk for complicated grieving
Readiness for enhanced power
Powerlessness
Risk for powerlessness
Impaired individual resilience

Risk for compromised resilience
Chronic sorrow
Stress overload

Neurobehavioral stress

Risk for disorganized infant behaviour
Autonomic dysreflexia
Risk for autonomic dysreflexia
Disorganized infant behaviour
Readiness for enhanced organized infant behaviour
Decreased intracranial adaptive capacity

Life principles

Beliefs

Readiness for enhanced hope
Readiness for enhanced spiritual well-being

Values/beliefs/action congruence

Readiness for enhanced decision-making
Decisional conflict
Moral distress
Non compliance
Impaired religiosity
Readiness for enhanced religiosity
Risk for impaired religiosity
Spiritual distress
Risk for spiritual distress Safety /protection

Infection

Risk for infection

Physical injury

Ineffective airway clearance
Risk for aspiration
Risk for bleeding
Impaired dentation
Risk for dry eye
Risk for falls
Risk for injury
Impaired oral mucous membranes
Risk for perioperative positioning injury
Risk for peripheral neurovascular dysfunction
Risk for shock
Impaired skin integrity
Risk for sudden infant death syndrome
Risk for suffocation
Delayed surgical recovery
Risk for thermal injury
Impaired tissue integrity
Risk for trauma
Risk for vascular trauma

Violence

Risk for other-directed violence
Risk for self –directed violence
Self-mutilat8ion
Risk for self-mutilation
Risk for suicide

Environmental hazards

Contamination
Risk for contamination
Risk for poisoning

Defensive processes

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

Thermoregulation

Risk for imbalanced body temperature
Hyperthermia
Hypothermia
Ineffective thermoregulation Comfort

Physical comfort

Impaired comfort
Readiness for enhanced comfort
Nausea
Acute pain
Chronic pain

Environmental comfort

Impaired comfort
Readiness for enhanced comfort

Social comfort

Impaired comfort
Social isolation Growth and development Growth
Risk for disproportionate growth
Delayed growth and development

Development

Risk for delayed development
Delayed growth and development

Adapted from:

Herdman, T.H. (Ed.) NANDA International Nursing Diagnoses: Definitions & Classifications, 2012-2014. Oxford: Wiley-Blackwell.