nursing care plan template
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?
nursing care plan template
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?
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.