Nursing Care Plans And Individual Client Care Needs
This book is intended to facilitate the care planning process for nurses working with pediatric clients based on recognized nursing standards. Each of the nursing diagnoses is from NANDA's Taxonomy II (NANDA, 2003). The outcome criteria include the appropriate Nursing Outcome Classification
(NOC) as well as prompts to assist the user in developing individualized outcomes. This text also contains suggested Nursing Intervention Classifications (NIC) for each nursing diagnosis in addition to suggested comprehensive and individualized interventions for each diagnosis.
Each section begins with essential introductory information about the condition and the current medical management when appropriate. A thorough assessment of the client is essential to developing a plan of care. The user is prompted to insert specific client data into the care plan at strategic points in each diagnosis. The user is offered a variety of common and additional nursing diagnoses for each condition including:
1. The etiology (related to) for each diagnosis using specific client data obtained in the assessment.
2. Possible defining characteristics, with prompts for individualization, which support the diagnosis.
3. A client goal related to the nursing diagnosis with a prompt to identify an appropriate time frame for evaluation of the outcomes.
4. Measurable outcome criteria requiring the use of specific client data and individualized parameters.
5. Comprehensive and detailed nursing interventions with guidance to individualize care for the specific client.
6. Rationales for the nursing interventions to demonstrate evidence-based practice.
7. Evaluation based on individual client information. The user is prompted to evaluate goal achievement and present the specific client data called for in the outcome criteria.
The nursing care plans provided in this text are intended to serve as a framework on which to design individualized client care reflecting current nursing standards of care. The user must first obtain comprehensive, reliable, and detailed assessment information for the particular client using all available sources. The initial assessment data should then be interpreted and organized into categories reflecting prioritized client needs. Frequently, after reflecting on the initial assessment, the nurse will find that additional focused assessment data must be obtained before care can be planned. Appropriate nursing diagnoses are then selected and prioritized. Individual client data are the defining characteristics that support the choice of nursing diagnosis. A specific goal and the necessary outcome criteria that will be used to identify when the goal has been met should be based on the defining characteristics. Outcome criteria reflect the individual client's capabilities and expectations. The nurse then selects a comprehensive array of interventions to provide current evidence-based client care directed toward the outcomes and resolution of the problem. Interventions should also be prioritized and may include additional ongoing assessments, therapeutic nursing activities, collaborative interventions, client and family teaching, and referrals. Current standards of care for pediatric nursing practice have been incorporated throughout the text. Every effort has been made to prompt the user to insert individual client data and to specify the parameters of care as the care plan is developed. Thoughtful use of this text will guide the user to develop comprehensive individualized care plans based on current scientific knowledge and evidence for best practices.
The process for planning individualized care involves the same steps as the nursing process.
1. Collect assessment data from all available sources including the client, the family, other providers, and the chart. Chart data may include: nurse's notes or flow sheets; laboratory, diagnostic, or surgical reports; progress notes from dietary, rehab, or physical therapy; the physician's history and physical, and progress notes. Assess the client's current status through the interview, observation, and physical examination. After studying the health record and obtaining assessment data, organize the information into prioritized problem or client need categories.
2. Identify viable nursing diagnoses and potential client risks suggested by the categories of assessment data. Review the appropriate chapter in this text and review the nursing diagnoses provided for the condition. Choose the diagnoses that fit the specific client. The diagnostic process is individualized by identifying "related to" factors and "defining characteristics" that flow from the comprehensive client assessment. For example,
"Acute pain related to surgical incision" is supported by the client data, "verbalizes pain at a 9 on a scale of 0-10." The client's own words and pain rating support the diagnosis and guide the nurse to choose an outcome criteria of "verbalizes pain as less than 9 on a scale of 1-10" and interventions that must include assessment of pain using a scale of 1-10.
3. Plan to identify and meet client goals using specific outcomes as evidence. The goal pertains to the diagnosis and moves the client toward resolution of the problem within a reasonable time frame. The outcome criteria included in the text indicate options to measure goal attainment and encourage specific qualifiers such as when, how much, and individual client variables to be added to individualize the plan. "Client will experience decreased pain within 24 hours" is a clear goal with an achievable target time. "Verbalizes pain as 5 or less on a scale of 1-10" would be a measurable outcome that, if based on the particular client situation and capabilities, individualizes the plan and indicates goal attainment.
4. Design interventions to meet the goal and resolve the nursing diagnosis. Choose interventions pertinent to the client that are consistent with the medical orders. Ongoing assessment of the client's pain perception, positioning, teaching the client to ask for medication before pain becomes severe, and the administration of pain medications, specifying the drug, dose, route, and times as ordered, are examples of both independent and collaborative nursing interventions, which would achieve the outcome, attain the goal, and resolve the "Acute Pain" diagnosis.
5. Evaluate the effectiveness of the plan. By setting a client goal and specific observable outcomes, the plan communicates the need for ongoing evaluation and updating. Evaluation of the outcome criteria at the specified time will either indicate resolution of the problem or the need to continue or revise the care plan.
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