Nursing Care planning

3
• Definition
 Involves determining before and the
strategies or course of actions to be
taken before implementation of
nursing care.
Third step of the Nursing Process
NURSING CARE PLANING
Prepaired By Mubarak Raas

• Nursing care plans are an important part of
providing quality patient care.
• They help to define the nurses' role in the
patient's treatment,
• provide consistency of care and allow the
nursing to customize its interventions for
each patient.
• Additionally, it promotes holistic treatment of
the patient and helps define specific goals
for the patient.
• Defining Patient Goals
Purpose of Nursing Care Planning

Steps Of Nursing Care Planning

1. Establish/Set priorities
• Priority – It is a decision-making process that ranks
the order of nursing diagnosis in terms of importance
to the client.
Guideline for setting priorities:
1. Life-threatening situations should be given highest
priority.
2. Use the principle of ABC’s (airway, breathing,
circulation)
3. Use Maslow’s hierarchy of needs.
4. Consider something that is very important to the
client.
5. Actual problems take precedence over potential
concerns.

Planning – Begin by
prioritizing client problems
• Prioritize list of client’s
nursing diagnoses using
Maslow
• Rank as high,
intermediate or low
• Client specific
• Priorities can change

Activities during Outcome
Identification
Establish client’s goals and outcome criteria
Client Goal
 Is an educated guess made as a broad statement
about what the client’s state or condition will be
AFTER the nursing intervention is carried out.
Planning Developing A Goal And
Outcome Statement

Planning- Types of goals
Short term goals
Short term goal can be achieved in a reasonable
amount of time ( few hours to few days)
Long term goals
Long term goals may take weeks/months to be
achieved

• Short Term Goal (STG) – can be met in a short
period (within days or less than a week)
• Long Term Goal (LTG) – requires more time
(several weeks or months)
• Outcome Criteria – are specific, measurable,
realistic statements goal attainment. They are
written in a manner that they answer the questions:
who, what actions, under what circumstance, how
well and when.
GOALS MAY BE SHORT TERM OR LONG TERM

Specific
Measurable
Achievable
Relevant
Time Bound
THE CHARACTERISTIC OF WELL-STARED OUTCOME CRITERIA ARE:

EXAMPLE OF GOALS AND OUTCOME CRITERIA
1. Goal – The client will report a decreased anxiety
level regarding Surgery.
• Possible Outcome Criteria:
• The client discusses fears & concern regarding
surgical procedure after client teaching.
• After client teaching, the client verbalizes decreased
anxiety.
• The client identifies a support system and strategies
to use to reduce stress and anxiety related to the
surgical experience.

2. Goal – The client will demonstrate safety habits when
performing activities of daily living.
Possible Outcome Criteria:
• Immediately after instruction by the nurse, the client
uses call light system for assistance when needs to
use the bathroom.
• The client demonstrates safety practices when
dressing and doing personal hygiene.
• The client uses over-the-bed lights, non-skid slippers
when transferring to chair or getting out of bed.
• The client identifies modification for home safety
(removal of throw pillows, installation of hand rails in
hallway, better lighting of hallway and stairway), 12
hours after nurse’s instruction about home safety.

3. Goal – The client will mobilize lung secretions.
• After teaching session, the client demonstrates
proper coughing techniques.
• The client drinks at least 6 glasses of water per
day while in the hospital.
• The caregiver or significant other demonstrates
proper technique of chest physiotherapy including
percussion, vibration and postural drainage
before discharge.

Planning-select interventions
• Interventions are selected and written.
• The nurse uses clinical judgment and professional
knowledge to select appropriate interventions that
will aid the client in reaching their goal.
• Interventions should be written clearly and
specifically.

Interventions – 3 types
• Independent ( Nurse initiated )- any action the
nurse can initiate without direct supervision
• Dependent ( Physician initiated )-nursing actions
requiring MD orders
• Collaborative- nursing actions performed jointly
with other health care team members

Bronchial asthma is a disease caused by increased
responsiveness of the tracheobronchial tree to
various stimuli. The result is paroxysmal
constriction of the bronchial airways. Bronchial
asthma is the more correct name for the common
form of asthma
Example Of Nursing Care Plan Of Patients With
Bronchial Asthma

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
• Dyspnea
• Coughing
• Tachypnea
• Tachycardia
• Chest
tightness
• Restlessness
• Anxiety
• Cyanosis
• Loss of
consciousness
• Changes RR
Ineffective
airway
clearance RT
bronchoconst
riction,
increased
mucus
production,
and
respiratory
infection AEB
wheezing,
dyspnea, and
cough
Patient will
maintain/improve airway
clearance AEB absence of
signs of respiratory
distress
Patient will verbalize
understanding that
allergens like dust, fumes,
animal dander, pollen, and
extremes of temperature
and humidity are irritants
or factors that can
contribute to ineffective
airway clearance and
should be avoided.
Patient will demonstrate
behaviors that would
prevent the recurrence of
the problem
- Administer
medications as
ordered.
- Teach and
encourage the use
of diaphragmatic
breathing and
coughing
exercises.
- Teach early signs
of infection that
are to be reported
to the clinician
immediately.
- Instruct
patient to avoid
bronchial irritants
such as cigarette
smoke
- Patient maintains
airway clearance
AEB absence of
signs of respiratory
distress
- Patient verbalize
understanding that
allergens like dust,
fumes, animal
dander, pollen,
and extremes of
temperature and
humidity are
irritants or factors
that can contribute
to ineffective
airway clearance
and should be
avoided.
Example Of Nursing Care Plan Of Patients With Bronchial Asthma

Diabetes care plan
Client Situation
Mr. S., client with type 2 diabetes (non–insulin-dependent) for 5 years, presented
to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left
foot.
Screening studies done in the doctor’s office revealed blood glucose of 356, he is
admitted to the hospital.
Assessment
• History of slow healing: lesion L foot, 3 weeks’ duration
• Extremities: Numbness/tingling: “My feet feel cold and tingly
• like sharp pins poking the bottom of my feet when I walk the quarter mile
to the mailbox.”
• Cough/character of sputum: occ./white
• Change in frequency/amount of urine: yes/voiding more lately
• Foot pain

 Nursing Diagnoses
 impaired Skin Integrity related to pressure, altered
metabolic state, circulatory impairment, and decreased
sensation, as evidenced by draining wound L foot.
 Goal : Blood Glucose Control
• Client Will Demonstrate correction of metabolic state as
evidenced by FBS less than 120 mg/dL within 36 hr (6/30
0700).
 Goal: Wound Healing: Secondary
• Client Will Be free of purulent drainage within 48 hr (6/30
1900). Display signs of healing with wound edges
clean/pink within 60 hr (discharge) (7/1 0700).

NURSING INTERVENTION
• Irrigate wound with room temperature sterile NS
tid.
• Assess wound with each dressing change.
• Apply wet to dry sterile dressing.
• Administer Medications as ordered
 Rational
• Cleans wound without harming delicate tissues.
• Provides information about effectiveness of therapy.
• Keeps wound clean/minimizes cross contamination.
• Adhesive tape may be abrasive to fragile tissues.
• Treatment of infection/prevention of complications.

 Nursing Diagnoses
 acute Pain related to (open wound L foot), as evidenced
by verbal report of pain and guarding behavior.
 Goal : Pain Control
 Possible Outcome Criteria:
• Client will Report pain is minimized/relieved within 1 hr of
analgesic administration (ongoing).
• Report absence or control of pain by discharge (7/1).
 NURSING INTERVENTION
• Determine pain characteristics through client’s description.
• Place foot cradle on bed;
• encourage use of loose-fitting
• Administer analgesic as ordered
• Document effectiveness.

Nursing Diagnoses
• ineffective peripheral Tissue Perfusion related to decreased
arterial flow evidenced by decreased pulses, pale/cool feet;
thick, brittle nails; numbness/tingling of feet “when walks ¼
mile.”
 Goal: Knowledge:
 Diabetes client will Verbalize understanding of relationship
between chronic disease (diabetes mellitus) and circulatory
changes within 48 hr (6/30 1900).
 Demonstrate awareness of safety factors/proper foot care within
48 hr (6/30 1900).
 Maintain adequate level of hydration to maximize perfusion, as
evidenced by balanced intake/output, moist skin/mucous
membranes, adequate capillary refill less than 4 seconds
(ongoing).

 NURSING INTERVENTION
• Elevate feet when up in chair. Avoid long periods with feet
dependent.
• Assess for signs of dehydration.
• Monitor intake/ output.
• Encourage oral fluids.
• Recommend cessation of smoking.
• Discuss complications of disease that result from vascular
changes (i.e., ulceration, gangrene, muscle or bony structure
changes).

Nursing Diagnoses
 Learning Need regarding diabetic condition related to misinterpretation
of information and lack of recall as evidenced by inaccurate follow-
through of instructions regarding home glucose monitoring and foot
care, and failure to recognize signs symptoms of hyperglycemia.
 Goal: Teaching: Disease Process
 Diabetes client will Perform procedure of home glucose monitoring
correctly within 36 hr.
 Verbalize basic understanding of disease process and treatment within
38 hr.
 Explain reasons for actions within 28 hr.
 Perform insulin administration correctly within 60 hr.

 NURSING INTERVENTIONS
 Determine client’s level of knowledge, priorities of learning needs,
desire/need for including wife in instruction.
 Show film “Living with Diabetes” 6/29 4 PM, when wife is visiting.
Include in group teaching session 6/30 AM.
 Discuss factors related to/ altering diabetic control (e.g., stress,
illness, exercise).
 Teach signs/symptoms of hyperglycemia (e.g., fatigue,
nausea/vomiting, polyuria and polydipsia).
 provide information about necessity for routine examination of feet
and proper foot care (e.g., daily inspection for injuries, pressure
areas, corns, calluses; proper nail cutting; daily washing, application
of good moisturizing lotion Recommend wearing loose-fitting socks
and properly fitting shoes (break new shoes in gradually) and
avoiding going barefoot.

Nursing Care Planning for Hypertension Patient
Nursing
assessment
Nursing
diagnosis
Nursing care
planning
Nursing intervention Nursing
Evaluation
Subjective;
 Headache,
shortness
of breath,
fatigue,
confusion
and chest
pain
Objective
 Bp 160/90
mmhg
Risk for
decreased
cardiac
output relate
d to increased
afterload,
vasoconstricti
on,
myocardial
ischemia,
ventricular
hypertrophy
Goal: afterload is not
increased, there was
no vasoconstriction,
and myocardial
ischemia does not
occur.
Expected outcomes:
 Maintaining blood
pressure within an
acceptable range.
 Showed stable
cardiac rhythm
and frequency.
 Participate in
activities that
lower blood
pressure
1. Monitor and measure
blood pressure in both
hands, using a cuff and
proper techniques in
terms of measuring blood
pressure.
2. Auscultation of breath
sounds and heart tone.
3. Observe skin color,
moisture, temperature
and capillary refill time.
4. Note the presence,
quality of the central and
peripheral pulses.
5. Maintain restrictions on
activities such as rest in
bed or chair.

Nursing Care Planning for Hypertension Patient
Nursing
assessmen
t
Nursing
diagnosis
Nursing care
planning
Nursing
intervention
Nursing
Evaluatio
n
Subjective;
 Headache,
shortness
of breath,
fatigue,
confusion
and chest
pain
Objective
 Bp 160/90
mmhg
2. Acute pain:
headache
related to
increased
cerebral
vascular
pressure.
Goal: The pressure
does not increase
cerebral vascular
Expected Outcomes:
Patients revealed the
absence of headache
and looked
comfortable.
1. Maintain bed rest,
quiet neighborhood,
a little light.
2. Limit of patients in
the activity.
3. Minimize disruption
and environmental
stimuli.
4. Give a fun action
according to
indications such as
ice packs, the
position of comfort,
relaxation
techniques,
counseling
5. Medical
collaboration in
providing analgesic
and sedative drugsPrepaired By Mubarak Raas

RHEUMATOID ARTHRITIS
Rheumatoid Arthritis is a chronic inflammatory disorder that
typically affects the small joints in your hands and feet. Unlike
the wear-and-tear damage of Osteoarthritis, Rheumatoid
Arthritis affects the lining of your joints, causing a painful
swelling that can eventually result in bone erosion and joint
deformity.
As an autoimmune disorder, Rheumatoid Arthritis occurs when
your immune system mistakenly attacks your own body’s
tissues. In addition to causing joint problems, Rheumatoid
Arthritis sometimes can affect other organs of the body — such
as the skin, eyes, lungs and blood vessels.

 Signs and Symptoms of Rheumatoid Arthritis May
Include:
 Tender, warm, swollen joints
 Morning stiffness that may last for hours
 Firm bumps of tissue under the skin on your arms
(rheumatoid nodules)
 Fatigue, fever and weight loss
Causes of Rheumatoid Arthritis?
The actual cause of RA is unknown, but it is thought to be
triggered by environmental factors, such as infections with
viruses or bacteria, in people with a genetic predisposition
to the disease.
RHEUMATOID ARTHRITIS

Nursing Care Planning for RHEUMATOID ARTHRITIS Patient
Nursing
assessment
Nursing
diagnosis
Nursing care
planning
Evaluation
Subjective
Pain
Objective:
N/A
Problem
Chronic Pain
R/T
Progression
of joint
deterioration
, injury,
surgical
procedure,
and chronic
kidney
disease
AEB
as
evidenced
by patient
self report of
pain level.
Long Term:
Client will function on
acceptable ability
level with minimal
interference from pain
and medication side
effects two months.
Short Term:
Use pain rating scale
to identify current
level of pain intensity,
and determine
comfort/function goal.
1. Tell the client to
report pain location,
intensity and quality
when experiencing
pain. Assess and
document the
intensity of the pain
with each new report
of pain and at
regular
intervals. Systemati
c ongoing
assessment and
documentation
provide the direction
for pain treatment
plans ; adjustments
are based on the
client’s response.
The pt stated
that his pain
scale is 2

Parkinson's Disease
Parkinson's disease is one of a larger group of neurological conditions called
motor system disorders.
In the normal brain, some nerve cells produce the chemical dopamine, which
transmits signals within the brain to produce smooth movement of muscles. In
Parkinson's patients, 80 percent or more of these dopamine-producing cells are
damaged, dead, or otherwise degenerated. This causes the nerve cells to fire
wildly, leaving patients unable to control their movements. Symptoms usually
show up in one or more of four ways:
• tremor, or trembling in hands, arms, legs, jaw, and face
• rigidity, or stiffness of limbs and trunk
• bradykinesia, or slowness of movement
• postural instability or impaired balance and coordination.

Symptoms of Parkinson's Disease
• Tremors- the most noticeable early symptom. It often begins very
localised, such as in a finger of one hand. Over time it spreads
throughout the whole arm. Tremors often occur when the limb is at rest
or when held in a stiff, unsupported position. Tremors also may occur in
the lips, feet or tongue.
• Bradykinesia- slowness of motion. The individual's movements
become increasingly slow and over time muscles may randomly
"freeze".
• Akinesia- muscle rigidity. Often begins in the legs and neck.
• Digestion problems- the ability to process food slows down, resulting
in low energy and constipation.
• Depression- Parkinson's causes chemical changes in the brain that may
result in depression.
• Low Blood Pressure- can result in light headedness and fainting.
• Temperature sensitivity- perception of temperature can be affected,
and may result in hot flashes and excessive sweating.

Nursing Care Planning for Parkinson's Disease Patient
Assessment diagnosis planning intervention evaluation
Subjective
client said it was difficult
to do activities
Pt demonstrates
difficulty with any
movement of the left
lower extremity.
Objective
Pt states that his pain
level is a 9 on a 10-point
pain rating scale.
Pt grimaces during any
kind of motion or
movement of his left
lower extremity
Problem:
Impaired
physical mobility
related to muscle
stiffness and
tremors
AEB Grimacing
during
movement or
activity Pt
complaints about
pain and
discomfort Pt
pain rating of 9
out of 10
Long Term:
Pt will be able to
ambulate around
the nurses’
station 2X by
discharge.
Short Term:
Pt will perform
passive range of
motion exercises
by the end of this
shift.
Apply any ordered
brace before
mobilizing the client.
Increase
independence in
ADLs
Obtain any assistive
devices needed for
activity.
Assess the pt’s pain
by using the 10-point
pain rating scale q4
hrs. or PRN.
Before activity, treat
pain.
Goal met. Pt was
able to ambulate
around the nurses’
station by discharge.
Pt was able to
complete his activity
more than twice.
Pt did not complain
of any pain or
discomfort upon
ambulation.
Pt states “I feel like
I’m finally getting
back to my old self.”
Goal met. Pt able to
fully complete
passive range of
motion exercises
with assistance from
the staff by the end
of this shift. Pt did
not complain of any
pain associated with
exercise session.

Alzheimer’s disease
Alzheimer’s disease is a progressive and irreversible, degenerative, fatal disease and is the
most common form of dementia among older people. Dementia is a brain disorder that
seriously affects a person’s ability to carry out daily activities. It usually begins after age 60
and the risk goes up as you get older. Risk is also higher if a family member has the disease.
Progression of the disease is done in phases until all cognitive function is destroyed.
Pathologic consequences include the loss of neurons in multiple areas within the brain,
atrophy with wide sulci and dilated ventricles of the brain, the presence of plaques composed
of neurites, astrocytes, and glial cells that surround an amyloid center, and neurofibrillary
tangles.
Symptoms seen in AD are the result of the destruction of numerous neurons in the
hippocampus and the cerebral cortex. The enzyme choline acetyltransferase, has a decreased
action with AD patients, which results in impaired conduction of impulses between the nerve
cells caused by lack of acetylcholine production.
Currently, no treatment can stop the progression of the disease. However, some drugs may
help keep symptoms from getting worse for a limited time

NR Assessment NR Diagnosis NR Planning NR Intervention NR Evaluation
Disorientation to
time, and place.
Decreased ability
to reason or
conceptualize
Inability to
calculate
Memory loss
Inability to follow
Dysphagia
Convulsions
Inappropriate
social behavior
Paranoia
Combativeness
2. Chronic
Confusion related
to Alzheimer’s
disease Possibly
evidenced by
Decreased ability
to interpret one’s
environment
Decreased
capacity for
thought
Altered
interpretation
Patient will
have minimal
confusion,
cognitive
impairment,
and other
dementia
manifestations.
Patient will
have stable,
safe
environment
with routine
scheduling of
activities to
decrease
anxiety and
confusion.
Maintain consistent
scheduling with
allowances for
patient’s specific
needs, and avoid
frustrating situations
and overstimulation.
Assists patients with
early AD to
remember location of
articles and facilitates
some orientation.
Instruct family
regarding avoidance
of arguing with
patient about what he
thinks, sees, or hears.
The Patient
maintains
minimal
confusion,
cognitive
impairment, and
other dementia
manifestations.
The Patient
demonstrates
stable, safe
environment
with routine
scheduling of
activities to
decrease
anxiety and
confusion.

Nursing Care Plan for Preeclampsia
Preeclampsia is a collection of symptoms that occur in pregnant women,
maternity and childbirth consisting of hypertension, edema and proteinuria, but
show no signs of vascular abnormalities or hypertension before, while the
symptoms usually appear after age 28 weeks gestation or more.
Clinical manifestations
Signs of preeclampsia usually arise in the order
• excessive weight gain, edema, hypertension, and proteinuria occur.
• Subjective symptoms: headache frontal area, epigastric pain; impaired
visual acuity; blurred vision, scotoma, diplopia; nausea and vomiting.
• Other cerebral disorders: increased reflexes, and not quietly.
• Examination: high blood pressure, reflexes increased and proteinuria in
the laboratory.

Nursing Care Planning for Preeclampsia Patient
Nursing
assessment
Nursing
diagnosis
Nursing care
planning
Evaluation
Subjective
headache,
epigastric pain;
blurred vision,
nausea and
vomiting.
Examination:
high BP,
Edema and
proteinuria in
the laboratory.
Problem
Ineffective
Tissue
Perfusion:
cerebral,
renal,
cardiac R/T
impaired
circulation.
AEB high
BP
Gaoals:
The circulation of
the body is not
impaired.
Expected outcomes
Patients
demonstrating an
improved tissue
perfusion as
indicated by: blood
pressure within
acceptable limits,
no complaints of
headache, dizziness,
Stable vital signs.
Urine output 30 ml /
min.
2. Measure the input
and discharge.
3. Observe the sudden
hypotension.
4. Monitor electrolytes,
creatinine according
to medical advice.
5. Maintain fluids and
medications
according to medical
advice.

Nursing Care Planning for Preeclampsia Patient
Nursing
assessmen
t
Nursing
diagnosis
Nursing care
planning
Nursing
intervention
Nursing
Evaluatio
n
Subjective;
 Headache,
shortness
of breath,
fatigue,
confusion
and chest
pain
Objective
 Bp 160/90
mmhg
2. Acute pain:
headache
related to
increased
cerebral
vascular
pressure.
Goal: The pressure
does not increase
cerebral vascular
Expected Outcomes:
Patients revealed the
absence of headache
and looked
comfortable.
quiet neighborhood,
a little light.
2. Limit of patients in
the activity.
3. Minimize disruption
and environmental
stimuli.
4. Give a fun action
according to
indications such as
ice packs, the
position of comfort,
relaxation
techniques,
counseling
5. Medical
collaboration in
providing analgesic
and sedative drugsPrepaired By Mubarak Raas

Nursing Care Plan for Placenta Previa
Placenta Previa is abnormally located placenta, which is on the lower
uterine segment so as to cover part or all of the opening of the birth canal.
The exact cause of placenta previa is unknown. But the reduced vascularity
in the lower uterine segment due to uterine scar surgery, molar pregnancy,
or tumors may cause Placenta Previa
Clinical Symptoms
 Bleeding without pain, gestational age over 22 weeks.
 The presence of anemia and shock in accordance with the discharge of
blood.
Physical examination
 External examination of the presenting part is usually not entered the
pelvic inlet.
 No abnormalities of the pelvic location of the fetus.Prepaired By Mubarak Raas

Nursing Care Planning for Placenta Previa Patient
Nursing
assessment
Nursing
diagnosis
Nursing care
planning
Nursing
intervention
Nursing
Evaluatio
n
 Bleeding
without pain,
gestational age
over 22 weeks.
 Recurrent
bleeding.
 The presence
of anemia and
shock in
accordance
with the
discharge of
blood.
 Palpable
placental tissue
in the vagina.
Risk Fluid
Volume Deficit
related to
excessive
bleeding due
to abnormal
placental
implantation,
AEB
Recurrent
bleeding
 Goal:
 Fluid volume needs
of clients are met.
 Expected Outcomes:
 Clients can indicate
stability /
improvement of
fluid balance as
evidenced by stable
vital signs, capillary
refill quickly, as well
as expenses and
adequate urine
specific gravity
individually.
1. Evaluation, report,
and record the
number and nature
of blood loss.
2. Do bed rest.
3. Position the mother
with the right, with
the pelvis elevated
supine or semi-
Fowler position.
4. Monitor uterine
activity, fetal status,
and presence of
abdominal
tenderness.

Nursing Care planning

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