GUIDELINES FOR COMPLETING THE NURSING CARE PLAN by po2347

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									     GUIDELINES FOR COMPLETING THE NURSING CARE PLAN
A.     Identifying data should be appropriately addressed.
       1.     Student’s name
       2.     Date of care plan development
       3.     Client’s initials
       4.     Client’s age and stage of development
       5.     Nursing system(s) for client care
                     a.       /Wholly compensatory nursing systems
                     b.       Partly compensatory nursing systems
                     c.       Supportive-educative (developmental) nursing system
       6.     Name of faculty member requesting care plan assignment
       7.     Name of health care agency when client is enrolled

       *     The appropriate system(s) is/are associated with the question: Who
             can or should perform these self-care operations that require
             movements in space and controlled manipulation? If the answer is
             the nurse, the system is wholly compensatory because a nurse
             should be compensating for a patient’s total inability for (or
             prescriptions against) engaging in self-care activities that require
             controlled ambulation and manipulative movements. If the answer
             is that the patient can perform some but not all self-care actions
             requiring controlled ambulation and manipulative movements, then
             the nursing system should be considered partly compensatory. If
             the answer is that the patient can and should perform all self
             care actions requiring controlled ambulation and manipulative
             movements, the nursing system should be of the supportive-
             educative (developmental) type.

B.     Assessment (begins with first nurse/client interaction)
       1.   Data Collection
            a.    Subjective data = what the client or significant other,
                  perhaps a substitute self-care agent, says about the health
                  care situation or status of an individual or group identified as
                  the recipient of health care.
            b.    Objective data = information obtained by the health care
                  provider via use of the five senses as incorporated in the
                  skills of health assessment: Inspection, Percussion,
                  Palpation and Auscultation. Objective data also includes
                  information obtained via laboratory tests, diagnostic studies
                  and written information disclosed by professional responsible
                  for the care of the client in question.
            c.    Universal Self-Care Requisites = guidelines for obtaining a
                  Nursing History.
            d.    Therapeutic Self-Care Demands= In concrete situation
                  where persons take care of themselves or in dependent care
                 or in nursing situations, therapeutic-self care demand is a
                 time specific calculation of the sets of actions judged to have
                 validity and reliability in controlling factors that affect human
                 functioning and development. The calculation is based on
                 data about individuals and their situations. Control or various
                 degrees of regulations of factors, means keeping factors at
                 values which are within the range that is compatible with
                 human life, human development, health and well-being
                 (Orem, 1991).

   BASIC CONDITIONING FACTORS that affect an individual’s ability to
    engage in self care or affect the kind and amount of self care required are:
        o Age
        o Gender
        o Developmental Stage
        o Health State
        o Sociocultural Orientation
        o Health Care System Factors (Medical diagnostic and treatment modalities)
        o Family System Factors
        o Pattern of Living (including activities regularly engaged in )
        o Environmental Factors
        o Resource Availability and adequacy

(This list should be amended whenever a new factor is identified )

A part of data collection is identifying assets and limitations which may help or
hinder the client’s ability to practice self-care.

    2.    Nursing Diagnosis –the problem, real or potential, identified by the
          nurse and based on information acquired via data collection. The
          diagnosis leads itself to independent nursing actions which promote
          optimum attainment of basic human needs necessary for
          maintenance of a health state.
    3.    Self-Care Deficit (SCD) – an inability to engage in self-care which
          occurs when the self-care agent is unable to meet the therapeutic
          self-care demand (TSCD) as a result of one of the basic
          conditioning factors.

								
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