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.
Pages to are hidden for
"GUIDELINES FOR COMPLETING THE NURSING CARE PLAN"Please download to view full document