PLAN OF CARE
PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED PATIENT ASSESSMENT DATA OPTIMAL PATIENT OUTCOME or GOAL
Patient problem/issues/need - which is related to insert
Patient problems/issues/needs can be actual present and occurring now
Or potential when the patient is considered to be ‘at risk of’. As evidenced by (or how do we know this problem exists)
Objective patient data
Subjective patient data
Lab and other test results What do we (patient and nurse) want to achieve:
Specific, measurable, attainable, realistic and time orientated (SMART goals)
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Nursing Care Plan Report - 2000 words
From your nursing care plan template select 2 physiological problems. These may be actual problems, potential problems or one of each. Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these.
For each of your chosen problems:
• Explain the pathophysiology and how this relates to the patients clinical presentation. I.e. What is happening in the body to cause the signs and symptoms that the patient has?
Identify the key nursing interventions required specifically to treat or prevent the problem you have chosen. These interventions should be supported by contemporary clinical guidelines, policies and high quality best-practice evidence. Nursing interventions should include a rationale supported by evidence. Nursing interventions may be
• Independent interventions – nurse led, nurse initiated
• Collaborative interventions – with other members of the multidisciplinary team
• Dependant interventions - for example dependent on a doctors order
These interventions should focus just on interventions which will specifically treat or prevent your chosen problems. Please do not include general nursing care which would be applicable here, or interventions which are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it).
• Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?
Include specific outcomes here appropriate for your patient. The idea is that if someone were to read your plan of care without knowing the patient they would still be able to achieve patient specific goals. For example, your patient might have a history of COPD with CO2 retention and the target oxygen requirements would be 88-92%. Instead of your outcome being ‘satisfactory oxygen saturations’ you should specify ‘oxygen saturations of 88-92%’. Instead of saying “acceptable BP” as an outcome, identify what range you want the BP to be in for your patient.
As this is a formal academic report you should include
- an introduction: identify which patient case study you are using and the purpose/direction of your report e.g. -... This report will discuss compartment syndrome and surgical wound breakdown as two actual problems experienced by Mr. Smith. The pathophysiology of these conditions will be outlined along with nursing interventions required to treat these problems...-
- a conclusion: 1 or 2 sentences only which sum up your work. The conclusion should not include references as it is a summary of your ideas only.
- at a third year BN level, for a 2000 word report you should have at least 20 high quality sources of evidence
Phlebitis or venitis is the inflammation of a vein, usually in the legs. It most commonly occurs in superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called thrombophlebitis or superficial thrombophlebitis.
Cause of metabolic acidosis is sepsis
Sepsis-induced tissue hypoperfusion leads to inadequate delivery of oxygen and nutrients to tissues.
Metabolic acidosis (do not mention sepsis)
Sepsis – actual problem (Metabolic acidosis/ hyperglycaemia/ hypovolaemic) damaged tissue and pain pathways
Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L ( 18 mg/dL) in the absence of hypovolemia.-
Neither patient is on vasopressors. Both have elevated lactate but neither have had fluid resuscitation yet. Which means both are septic but neither are in shock yet.
• You have to link these to this specific patient, so in each of these patients they would be the result of sepsis. In reality they could be caused by many different things, but this assessment is asking you to identify the pathophysiology of these problems and how these relate to the patients signs and symptoms, so in this case, yes, you would need to identify how these relate to sepsis or how sepsis has caused these.
DVT – potential problem
• The patient does not have an ACTUAL DVT so make sure you make your problem a POTENTIAL DVT and your signs and symptoms are the risk factors, and your pathophysiology is why these risk factors can cause blood clots.