Care Plan- RN

Instructions for particular sections in the document are found in the Blue highlighted rows below. Students
are expected to develop three NANDA Nursing Diagnoses/ Problem-Based Nursing Diagnoses with
supporting documentation. The first Nursing Diagnosis identified should be the priority nursing diagnosis.
This will be the nursing diagnosis used to develop the Care Plan. Before completing the Care Plan below,
visit DocuCare and review/chart the client’s assessment as instructed.

Priority- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis

1. Choose a NANDA or Problem-Based Nursing Diagnosis

2. The statement should list only one diagnosis and be listed using the following format- problem
followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale

Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the PRIORITY Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement
and as evidenced by sentence including rationale below:

#2- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis

1. Choose a NANDA or Problem-Based Nursing Diagnosis

2. The statement should list only one diagnosis and be listed using the following format- problem
followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale

Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the #2 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:

#3- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis

1. Choose a NANDA or Problem-Based Nursing Diagnosis

2. The statement should list only one diagnosis and be listed using the following format- problem
followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale

Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the #3 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:

Care Plan- Using the Priority Nursing Diagnosis, develop the plan of care.

Subjective Summary (Information stated by Objective Summary (Observable)

client)
Objective Data should be clear, concise and
Subjective Data should be clear, concise and specific to the Nursing Diagnosis
specific to the
Nursing Diagnosis Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
Example Subjective Data- what the client/family signs, lung sounds, urine output, laboratory data,
relates, states or reports. Client reports abdominal diagnostic testing (etc.) as related to the specific
pain. nursing diagnosis.

Subjective Data: Objective Data:

3 Types of Stimuli- Roy’s Adaptation Theory

Describe how the three stimuli are affected by the reviewing the data collected.

1. Focal stimuli are those which are most immediately confronting the human adaptive system
(for example: asthma)
2. Contextual stimuli are all other stimuli with effect on the focal stimuli (for example: dyspnea
while taking a shower)
3. Residual stimuli are environmental factors with unknown effects on the current situation (for
example: belief and thought about not being able to take a shower safely)
Describe:
Four Adaptive Modes- Roy’s Adaptation Theory

Describe the impact of the identified stimuli on the four Adaptive Modes of behavior (physiological,
self-concept, role function and interdependence).

Regulator Sub-System of Coping- The regulator subsystem is a person’s physiological coping mechanism. The
body attempts to adapt via regulation of our bodily processes, including neurochemical and endocrine systems.

1. Physiological- Behavior in this mode is a manifestation of the physiological activity of all the
cells, tissues, organs, & systems of the body.
 5 needs serve to promote physiological integrity, (oxygenation, nutrition, elimination,
activity and rest, and protection).
 4 processes which help maintain physiological integrity (senses, fluid and electrolytes,
neuro, and endocrine function)

Cognator Sub-System of Coping- The cognator subsystem is a person’s mental coping mechanism. A person uses
his brain to cope via self-concept, interdependence, and role function adaptive modes.

2. Self-Concept- Deals with the person’s beliefs & feelings about himself/herself. Basic
underlying need: psychic integrity (physical perceptions, ideals, goals, moral/ethical beliefs)

Physical self: How one sees his own physical being

 Body sensation: ability to express sensations/feel symptoms
 Body image: how one sees himself as a physical being

Personal self: How one views his qualities, values, worth

 Self-consistency: one’s self-description of qualities; also includes self-organization
behavior
 Self-ideal/self-expectancy: what one would like to do or be
 Moral-ethical-spiritual self: values, beliefs, religion self-esteem: the value one places
on himself/herself

3. Role Function: Involves the position one occupies in society; behaviors associated with one’s
position (role) in society. Basic underlying need: social integrity

Primary role: role based on age, sex, developmental state

Secondary role: role(s) a person assumes to complete tasks associated with a primary role or
developmental stage

Tertiary role: a role freely chosen; temporary; associated with accomplishments of tasks or
goals

4. Interdependence: Associated with one’s relationships and interactions with others and the
giving and receiving of love, respect, and value. Basic underlying need: nurturance and
affection

Significant others: intimate relationships (spouse, parent, God)

Support systems: less intimate relationships (coworkers, friends)
Giving behaviors: giving love, nurturance, affection
Receiving behaviors: receiving/taking in love, nurturance, affection
Describe:

Goals/ Outcomes (Short-term/ Long-term) including Timelines/ Timeframes

1. Each client should have one long-term and one short-term goal/ outcomes as part of the Care
Plan.
2. Goal/ Outcome statements should be specific (related to the nursing diagnosis/ problem-based
nursing diagnosis), measurable, achievable (realistic for the client), clear and concise (don’t
use increase or decrease without including baseline data, timelines/ timeframes should be
realistic and achievable.
3. Include a date or time at which the expected outcomes and nursing intervention are achieved or
evaluated (should be specific as “by discharge date” or “ongoing”).

Definitions:

Short-term Goals/ Outcomes: Those goals that are usually met before discharge or before transfer to a
less acute level of care.
Long-term Goals/ Outcomes: Those goals that may not be achieved before discharge but require
continued attention by client and/or significant others as indicated.
Short-term Goal:

Long-term Goal:

Nursing Interventions and Scientific Rationales including Best Evidence with References

Three nursing interventions should be identified for the priority NANDA Nursing Diagnosis/ Problem-
based Nursing Diagnosis. Nursing interventions should be concise, clear, specific, individualized and
accomplishable to client and/or family and significant other. Interventions should support the
identified goals listed above.

Scientific rationales should address how the interventions are going to solve the problem identified
and/or attain the outcomes. The rationales should be specific to the intervention and summarized in
your own words. There should be a rationale for each of the three nursing interventions. Each
rationale must be supported by a citation using APA 7th edition.
Nursing Intervention #1:
Rationale:

Nursing Intervention #2:

Rationale:

Nursing Intervention #3:

Rationale:

Evaluation of Interventions (Impact)

The Evaluation should address the client’s response to each of the three interventions of the priority
Nursing Diagnosis and if any modifications were needed. The discussion below should address if the
intervention was effective or not and if a change was needed to meet the identified goals.
Evaluation Nursing Intervention #1:

Evaluation Nursing Intervention #2:

Evaluation Nursing Intervention #3: