nursing care plan template

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?

 

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.