3 Guidelines for Nursing Care Plan -Hail University

7/30/2019 3 Guidelines for Nursing Care Plan -Hail University

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Kingdom of SaudiArabia

Ministry of HigherEducation

University of HailCollege Of Nursing

Guidelines for Review of Body Systems

Use the format below for review of body systems to complete all your assignments.

1. GENERAL:

[ ] Recent Weight Changes

[ ] Fever

[ ] Body Malaise (Vague feeling of discomfort)

[ ] Mood Changes

2. SKIN, HAIR AND NAILS

][Rashes

][Lesions

][Itching

][Color Change

][Dryness

[ ] Brittle nails

[ ] Cracking

[ ] Other, specify: ____________________________________________________________

3. HEAD:

[ ] Headache

[ ] Seizure

[ ] Fainting

[ ] Head injuries

[ ] Dizziness

4. EYES:

[ ] Changes in vision[ ] Blindness

[ ] Cataract

[ ] Diplopia

[ ] Redness

[ ] Pain

[ ] Photophobia

[ ] Glasses (last exam date and result)

[ ] Contact lenses (type)

[ ] Glaucoma

[ ] Drainage

[ ] Infection

[ ] Other, specify: ____________________________________________________________

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5. EARS:

[ ] Difficulty in Hearing/Deafness

[ ] Tinnitus

[ ] Vertigo

[ ] Infection

[ ] Discharge

[ ] Other, specify: ____________________________________________________________

6. NOSE AND SINUSES:

[ ] Nasal stuffiness

[ ] Frequent colds

[ ] Hay fever

[ ] Nose bleeds

[ ] Sinusitis

7. MOUTH, PHARYNX, AND NECK:

[ ] Bleeding from gums/teeth

[ ] Oral infection

[ ] Dental problems

[ ] Dentures (last exam, time, and result)

[ ] Hoarseness

[ ] Swelling in neck

[ ] Frequent sore throats

[ ] Lumps in the neck

[ ] Dysphagia

[ ] Stiffness in neck

[ ] Other, specify: ____________________________________________________________

8. BREASTS:

[ ] Pruritus, pain, or lumps

[ ] Nipple discharge

[ ] Dimpling of skin

[ ] Enlargement (gynecosmastia)

[ ] Performance of self breast exam

[ ] Mammograms (date and result)[ ] Steroids

[ ] Other, specify: ____________________________________________________________

9. LUNGS:

[ ] Shortness of breath

[ ] Dyspnea on exertion

[ ] Orthopnea

[ ] Pain with respiration

[ ] Cough

[ ] Sputum (color, frequency, quantity)[ ] Hemopteysis

[ ] Wheezing

[ ] Cyanosis

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[ ] Pneumonia

[ ] Bronchitis

[ ] Emphysema

[ ] Asthma

[ ] TB test (date and result)

[ ] TB exposure

[ ] Chest x-ray (date and result)

[ ] Other, specify: ____________________________________________________________

10. HEART:

[ ] High blood pressure

[ ] Heart murmurs

[ ] Paroxysmal nocturnal dyspnea

[ ] Chest discomfort/pain

[ ] Palpitations

[ ] Syncope (Fainting)

[ ] Rheumatic fever (date)

[ ] Coronary Artery disease[ ] Heart attack

[ ] ECG (result and date)

[ ] Other, specify: ____________________________________________________________

11. PERIPHERAL VASCULAR:

[ ] Edema

[ ] Swelling/pain in calves

[ ] Pain/ulcerations or discoloration of extremities

[ ] Muscle Cramps

[ ] Varicose veins

[ ] Other, specify: ____________________________________________________________

12. GASTROINTESTINAL:

[ ] Nausea

[ ] Vomiting

[ ] Hematemesis

[ ] Indigestion/heart burn

[ ] Abdominal pain

[ ] Jaundice

[ ] Hepatitis (type and date)

[ ] Melena (Black colored stool)

[ ] Clay colored stools (Dark brown stool)

[ ] Incontinence of stool

[ ] Diarrhea

[ ] Change in bowel habit

[ ] Constipation

[ ] Hemorrhoids

[ ] Excessive gas

[ ] Hernia[ ] Ulcer

[ ] Gall bladder stone/Colic

[ ] Pancreatic disease

[ ] Other, specify: ____________________________________________________________

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13. URINARY:

[ ] Frequency

[ ] Urgency

[ ] Infection

[ ] Dysuria

[ ] Nocturia

[ ] Hematuria[ ] Stream, site, and force

[ ] Hesitancy

[ ] Incontinence (stress, urge, dribbling)

[ ] Other, specify: ____________________________________________________________

14. MALE GENITALIA:

[ ] Penile discharge

[ ] Genital lesions

[ ] Testicular pain/mass

[ ] Syphilis (date and result)[ ] Gonorrhea

[ ] Sexual intercourse problems

[ ] Other, specify: ____________________________________________________________

15. FEMALE GENITALIA:

[ ] Vaginal discharge

[ ] Pruritus

[ ] Genital lesions

[ ] Painful intercourse

[ ] Post menstrual bleeding

[ ] Post coital bleeding

[ ] Pap smear (date and result)

[ ] Other, specify: ____________________________________________________________

16. ENDOCRINE:

[ ] Heat and cold intolerance

[ ] Thyroid problems

[ ] Neck surgery (type, date and result of biopsy)

[ ] Diabetes mellitus (type and date)

17. HEMATOPOIETIC:

[ ] Abnormal bleeding/bruising/petechia

[ ] Anemia

[ ] Blood transfusion (date)

[ ] Leukemia (type and date)

[ ] Other, specify: ____________________________________________________________

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18. SPINE AND EXTREMITIES: MUSCOLOSKELETAL

[ ] Arthritis

[ ] Joint stiffness

[ ] Joint swelling

[ ] Joint pain

[ ] Muscle weakness

[ ] Muscle cramps[ ] Backache

[ ] Limited range of motion (ROM)

[ ] Other, specify: ____________________________________________________________

19. SPINE AND EXTREMITIES: NEUROLOGICAL

[ ] Paresthesia/numbness

[ ] Paralysis (site)

[ ] Incoordination (Ataxia)

[ ] Disturbed balance

[ ] Blackouts[ ] Tics

[ ] Tremors

[ ] Spasms

[ ] Other, specify: ____________________________________________________________

20. PSYCHIATRIC (Problems in the following areas):

[ ] Spouse

[ ] Family history

[ ] Insomnia

[ ] Depression (interfering with ADL’s)

[ ] Anxiety (interfering with ADL’s)

[ ] Mood swings

[ ] Delusions

[ ] Hallucinations

[ ] Eating, sleeping, or memory problems

[ ] Other, specify: ____________________________________________________________

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Kingdom of SaudiArabia

Ministry of HigherEducation

University of HailCollege Of Nursing

Guidelines For Physical Assessments(Objective Data)

Use the following format to conduct and record results of physical examination for all assignments.

1. GENERAL:

Statement to include observed state of health, posture, appearance, body odors, manner, affect,

signs of distress, speech, and level of awareness.

2. VITAL SIGNS:

a) Temperature (T) b) Pulse (P)

c) Respiration (R)

d) Blood Pressure (BP)

e) Pain Score (PS)

3. NUTRITION:

1) DESCRIBE DIET AND DETERMINE THE FOLLOWING: WEIGHT LOSS, IDEAL BODY WEIGHT (IBW),

USUAL BODY WEIGHT (UBW), PRESENT BODY WEIGHT (PBW), ENERGY REQUIREMENTS, AND FLUID

REQUIREMENTS.

2) IN ADDITION IDENTIFY RISK FACTORS.

3) DETERMINE IBW AS FOLLOWS:

A. Adult Male:

Allow 106 pounds for the first 60 inches and add 6 pounds for each additional inch.

B. Adult Female:

Allow 100 pounds for the first 60 inches and add 5 pounds for each additional inch.

Determine weight loss as follows:

IBW - PBW UBW - PBW

---------------- X 100 = % IBW or ---------------- X 100% = % of weight loss

IBW UBW

Weight loss is considered significant if it fallls into the following guidelines:

1-2 % in a week.

5% in 1 month.

7.5% in 3 months.

10% in 6 months.

4) DETERMINE ENERGY REQUIREMENTS AS FOLLOWS:

Body weight in kilogram X 35Kcal.

5) DETERMINE FLUID REQUIREMENTS A FOLLOWS:

Body weight in kilograms X 35ml.

Note: Increase calories 7% and fluids 125ml for each 1 degree increase in temperature.

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6) DETERMINE BODY MASS INDEX (BMI) AS FOLLOWS:

a) Calculate BMI Using the Metric System

If you're using the metric system, you can learn how to calculate BMI by using thefollowing formula:

Weight in kilograms divided by height in meters squared (weight (kg) / [height (m)] 2 ).

Since height is commonly measured in centimeters, divide height in centimeters by 100 to obtain

height in meters.

An example of calculating BMI using the formula: Height = 165 cm (1.65 m), Weight = 68 kg

BMI Calculation: 68 ÷ (1.65)2 = 24.98

b) Calculate BMI Using the English System

With the English system, the BMI formula is:

Weight in pounds (lbs) divided by height in inches (in) squared and multiplied by a conversion

factor of 703 (weight (lbs) / [height (in)2 ] x 703).

Therefore, to calculate BMI, take the weight (lbs) and divide it by height (in). Take the result

of that calculation and divide it by height again. Then, multiply that number by 703. Round tothe second decimal place.

An example of calculating body mass index using the BMI formula: Weight = 150 lbs, Height =

5'5" (65 inches )

BMI Calculation: [150 ÷ (65)2] x 703 = 24.96

c) BMI Categories

Underweight = <18.5

Normal weight = 18.5–24.9

Overweight = 25–29.9

Obesity = BMI of 30 or greater

7) CONVERSIONS:

1 feet (ft) = 12 inches

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1 inch = 2.54 centimeters (cm)

1 feet = 30.49 centimeters (cm)

1 kilogram (kg) = 2.2 pounds (lbs)

4. MENTAL STATUS:

Record a statement about the observation of behavior, mood, thought process, thought content,

perceptions, and cognitive functions.

5. SKIN:

Note color, temp., texture, moisture, presence of lesions, mobility, turgor, and describe appearance

of nails.

6. HEAD:

Describe hair, scalp, skull, and results of cranial nerves testing.

7. EYES:

Report visual acuity, appearance of eyebrows, eyelids, eyelashes, lacrimal apparatus, sclera, cornea,

conjunctiva, corneal light reflection, pupilary light response, extra occular muscle movement,accommodation, peripheral vision.

8. EARS:

Record result of inspection, palpation of the outer ear, hearing acuity, whisper test.

9. NOSE AND SINUSES:

Report description of the external nose, nasal mucosa, septum, presence of tenderness,

transillumination.

10. MOUTH AND PHARYNX:

Record description of observations of lips, buccal mucosa, gums, teeth, roof of the mouth, tongue,

pharynx, movement of uvula and gage reflex.

11. NECK:

Note palpation of lymph nodes, thyroid gland, and position of trachea, presence or absence of

masses.

12. PERIPHERAL VASCULAR:

Record peripheral pulses, capillary refill, edema, skin temp., and enlarged nodes in lower

limbs.

13. THORAX AND LUNGS:

Record results of inspection, palpation, and auscultation of lungs. Note diaphragmatic

excursion.

14. HEART:

Record results of inspection, palpation, and auscultation of the heart, note apical pulse, presence of

extra heart sounds, or murmurs.

15. BREAST AND AXILLAE:

Record results of inspection and palpation of breast and axillae.

16. ABDOMEN:

Record result of inspection, palpation, percussion, and auscultation of abdomen. Note liver size,

palpable organs, tenderness, and umbilical reflexes.

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17. INGUINAL AREA:

Record results of inspection and palpation of inguinal area. Note presence or absence of

hernias.

18. SPINE AND EXTREMITIES: MUSCULOSKELETAL:

Record results of inspection and palpation of all joints. Note test results of ROM and muscle

strength of all extremities. Check for scoliosis.

19. SPINE AND EXTREMITIES: NEUROLOGICAL

Record results for reflex tests, gait, balance, and coordination. Note sensation to pain, temp. light

touch vibration. Note position discrimination.

NURSING PROCESS GUIDELINES:(Planning Expected Outcomes)

I. NURSING PROCESS

Is a systematic, patient-centered, goal-oriented method of caring to provide a frame work for nursing practice.

II. OBJECTIVES OF N P (NURSING PROCESS )

a) The steps of the nursing process are not separated items, but rather are parts of whole used to:

Identify needs of the patient.

Establish priorities of care.

Maximize strengths.

Resolve actual and/or potential patient problem.

Apply health promotion to possible for each patient

b) Documenting the nursing process; Is the ability to record communicated nursing skills:

o Accurately,

o Concisely ,

o Timely, and

o Relevant, to provide the member of the caregiver a complete picture of the patient’s health.

c) Phases:

1. Assessment - Cues and Evidence(Subjective& Objective Data)

2. Diagnosis (Nursing Diagnosis)

3. Planning (Goal and Objectives)

4. Implementation (Nursing Interventions)

5. And Evaluation.

1.1 Assessment: A systematic and continuous collection, validation and communication of patient data or data base; includes all

patient information, collected by the health care professionals to enables an effective plan of care to be implementedfor the patient.

1.1.1 Sources of Data:

a) Patient is the primary source of information.

b) Family & Significant others, friends.

c) Patient record , records from members of health care , provide essentiald) Information related to the patiente) Medical history, physical examination, & progress notes.

f) Laboratory test &other health professions.

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1.1.2 Types of Assessment:

a) Initial Assessment - is performed shortly after patient admission to a health agency or hospital

b) Focused Assessment - the nurse gathers data about a specific problem that has already been identifiedc) Emergency Assessment - the nurse performs this type of assessment on a physiological or psychological crisis

to identify the life - threatening problems

d) Time-lapsed Assessment - this assessment done to compare a patient’s current status to the base line dataobtained earlier

1.1.3 Methods of Assessment:

a) Observation b) Interviewing

Directive interview

Nondirective interview

4 - Physical examination techniques:

1. Inspection2. Palpation

3. Percussion4. Auscultation

1.1.4 Assessment Activities:

Identify assessment priorities determined by the purpose of the assessment and the patient condition.

Organize or cluster the data to ensure systematic collect

Establish the data base by:

a) nursing history

b) nursing examination

Review of patient record & nursing literature.

Patient consultation and health care personnel

Continuously update the database

Validate the data.

Communicate the data.

2.1 Nursing Diagnosis: Diagnosing (patient problem), the 2nd step in the nursing process.

Is a clinical judgment about individual, family or community response to actual or potential health problem. It provides

the bases for selection of nursing intervention.

2.1.1 Activities of Nursing Diagnosis:

Interpret & analyze patient data

Identify patient strength and health problem

Formulate and validate nursing diagnosis

Develop a prioritized list of nursing diagnosis

Detect & refer signs and symptoms that may indicate a problem beyond the nurse’s experience.

2.1.2 Parts of Nursing Diagnosis: Problem – the statement that describe the health problem of the patient clearly & concisely.

Etiology – the reason (etiology) that identifies the physiological, psychological social,spiritual andenvironmental factors related to the problem.

Defining characteristics (signs or symptoms)

a) The subjective and objective data that signal the existence of the problem.

Characteristic Etiology Problem

Dry Skin, Dryness of the Mouth Diarrhea Deficient fluifd volume

b) Differentiating Nursing Diagnosis versus Medical Diagnosis:

Nursing Diagnosis Medical Diagnosis

Focus on unhealthy responses to health

Identify diseases and illness.

Identify Disease

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Describe problem treated by nurses

Within the scope of independent nursing

practice.

Describe problems for which the physicianDirects the primary treatment.

May change from day to day as the patient

Response changes.

Remains the same foe as long as the

disease is present.

c) Types of Nursing Diagnosis:

Types Definition

1. Actual Nursing Diagnosis Represent a problem that has been validated

by the presence of its characteristics, e.g.

impaired physical mobility, fatigue, ineffective

breathing pattern.

2. Risk Nursing Diagnosis It’s a clinical judgment that an individual ,

family , or community is more vulnerable(able) to develop the problem .e.g. Risk for

Deficient fluid Volume.

3. Possible Nursing Diagnosis Are statements describing a suspectedProblem .ex chronic low self –esteem.

4. Wellness Diagnosis It’s a clinical judgment about individual ,

group , or community in transition fromSpecific level of wellness to a higher level.e.g. Readiness for enhanced health

maintenance or Readiness for enhanced

Self-esteem.

5. Syndrome nursing Diagnosis a cluster of an actual or risk nursing diagnosis

suspected to be present according to certainEvents.

3.1 Planning

The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing

action in the resolution of nursing diagnoses and the development of the client’s plan of care.

3.1.1 Activities of Planning Phase (or step):

Establish priorities.

Identify expected patient outcome.

Select evidence- based nursing intervention.

Communicate the plan of care.

3.1.2 Stages of Planning:

a) Initial planning; is developed by the nurse, who performs the admission nursing history and the physicalassessment.

b) Ongoing planning; is carried by the nurse to keep the plan up date , by analyzing data to make plan more accurate .c) Discharge planning ; is best carried out by the nurse ,who has worked most closely with patient and family

3.1.3 The four critical elements of planning include:

• Establishing priorities

• Setting goals and developing expected outcomes (outcome identification)• Planning nursing interventions (with collaboration and consultation as needed)

• Documenting

4.1 Implementation: Consists of doing and documenting the activities that are the specific nursing actions needed to carry out theinterventions or nursing orders.

4.1.1 Types of Interventions:

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a) Direct Interventions: Actions performed through interaction with clients. b) Indirect Interventions: Actions performed away from the client, on behalf of a client or group of clients.

The nursing care plan consists of three components:

1. Expected outcomes2. Client problems (nursing Diagnosis )

3. Interventions

Types of Interventions:

a) Dependent b) Independent

c) Collaborative

5.1 Evaluation: The last phase of the nursing process, follows intervention of the plan of care, it’s the judgment of theEffectiveness of nursing care to meet client goals based on the client’s behavioral responses.

5.1.1 Evaluating: Measure how well the patient has achieved desired outcomes.

Final phase of nursing process

Occurs whenever nurse interacts with client

Determining status of outcomes

Systematic and ongoing appraisal

5.1.2. Outcomes:

Identify factors contributing to the patient's success or failure.

Modify the plan of care, if indicated.

A) Three possible outcomes of evaluation:

1. Outcomes not met – continue plan as written2. Outcomes not met – modify the plan

3. Outcomes met – terminate the plan

B) Factors affecting outcome attainment:

Facilitators

Barriers

C) Evaluating compliance:

Performance appraisal

Quality assurance

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3 Guidelines for Nursing Care Plan -Hail University

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