NURSING CARE PLAN

 POTENTIAL

IMPLEMENTATION
ASSESSMENT
PLANNING Rationale/Justifications
PROBLEM LIST (cues &
(objectives-long (Nursing Theories of Care,
DATE (according to evidences/ NURSING DIAGNOSIS EVALUATION
term Developmental stage,
priority) objective & Nursing Interventions References
& short term) tasks, Principles, EBP,
subjective)
Standards of Nursing
Practice)
Maslow’s first Subjective: Risk for After 8 hours of INDEPENDENT After 8 hours of
tier of powerlessness nursing nursing
physiological interventions, the  Identify  To assess causative NANDA 12th interventions, the
needs Objective: patient will be able situational factor that leads and Edition pg. 658 patient will be able
to: circumstances affects the problem to:
Maslow’s second
that made her
tier of safety  Express sense of
feel powerless  Express
control over the
Maslow’s third present situation  Passive individual NANDA 12th sense of
tier of belonging  Assess client’s may have more Edition pg. 658 control over
and future
self-esteem and difficulty being the present
Maslow’s fourth outcome; situation and
degree of assertive and
tier of self-worth  Acknowledge standing up for future as he
mastery client
reality that some rights. was able to
has exhibited in
Maslow’s fifth areas are verbalize.
life situations.
tier of achieving beyond
potential individual’s  Perception and NANDA 12TH  Acknowledge
 Determine Edition pg. 658 reality that
control knowledge of the
client’s some areas
condition serves as
perception and are beyond
Within 2 days of the basis for
proposed individual’s
providing proper appropriate nursing
treatment plan control
nursing interventions
interventions, pt.
will be able to:
#GOAL MET
 Make choices
related to and
be involved in
care.

DEPENDENT
 Manipulation NANDA 12TH
 Be alert for maybe used for Edition pg. 659
signs of management of
manipulative powerlessness
behavior and because of fear
note reactions of and distrust.
client and
caregivers.

COLLABORATIVE
 Improving skills NANDA 12th
 Refer to support to cope up Edition pg. 660
groups for challenges and to
chronic promote wellness
conditions or
disability or
counseling or
therapy, as
appropriate.
 NURSING CARE PLAN

 ACTUAL

IMPLEMENTATION
ASSESSMENT
PROBLEM LIST (cues & PLANNING Rationale/Justifications
DATE (according to evidences/ NURSING DIAGNOSIS (objectives-long term (Nursing Theories of Care, EVALUATION
priority) objective & & short term) Developmental stage,
Nursing Interventions References
subjective) tasks, Principles, EBP,
Standards of Nursing
Practice)
Maslow’s first tier Subjective: Disturbed Thought After 8 hours of INDEPENDENT After 8 hours of
of physiological “I can see he Process related to Panic nursing - Attempt to understand - Important clues to -Nurseslabs nursing
needs always experience level of anxiety as interventions, the the significance of these underlying fears and interventions,
delusions evidence by delusions. patient will be able beliefs to the client at the issues can be found in the the patient will
Maslow’s second whenever we go to: time of their client’s seemingly illogical be able to:
tier of safety together on presentation. fantasies.
places” as •Will refrain from •Will refrain
Maslow’s third tier verbalized by his acting on delusional - Recognizes the client’s - Recognizing the client’s -Nurseslabs from acting on
of belonging friend Jack. thinking. delusions as the client’s perception can help you delusional
perception of the understand the feelings he thinking.
Maslow’s fourth Objective: environment. or she is experiencing.
tier of self-worth • Inappropriate #GOAL MET
behavior - Explain the procedures - When the client has full -Nurseslabs
Maslow’s fifth tier • Delusional and try to be sure the knowledge of procedures,
of achieving •Hallucination client understands the he or she is less likely to
potential • Change in procedures before feel tricked by the staff.
personality carrying them out.
• Inability to
concentrate

DEPENDENT
- Interact with clients - If patients are -Nurseslabs
based on things in the restrained, they can
environment. Try to sustain injuries, including
distract client from their head injury from leading
delusions by engaging in with their heads to get out
reality-based activities of the bed.
(e.g., card games, simple
arts, and crafts projects
etc).

- Utilize safety measures - During acute phase, -Nurseslabs

to protect clients or client’s delusional
others, if the client thinking might dictate to
believe they need to them that they might have
protect themselves to hurt others or self to be
against a specific person. safe. External controls
Precautions are needed. might be needed.

COLLABORATIVE
-Refer to psychologist as -To identify high-risk -NANDA
appropriate. tasks and provide 14th
education about how to Edition pg.
stop being delusional. 483

-Encourage participation -To enhance self-esteem -NANDA

in self-help programs, and sense of self-worth. 14th
such as assertiveness Edition pg.
training, positive self- 483
image.

-Refer to other -Counseling is one of the - NANDA

resources, as indicated. resources a nurse can 14th
refer for the patient. Edition pg.
483
 NURSING CARE PLAN

 POTENTIAL

IMPLEMENTATION
ASSESSMENT
PROBLEM LIST (cues & PLANNING Rationale/Justifications
DATE (according to evidences/ NURSING DIAGNOSIS (objectives-long term (Nursing Theories of Care, EVALUATION
priority) objective & & short term) Developmental stage,
Nursing Interventions References
subjective) tasks, Principles, EBP,
Standards of Nursing
Practice)
Maslow’s first tier Subjective: Risk for injury related to After 8 hours of INDEPENDENT After 8 hours of
of physiological “Sometimes I don’t hallucinations and nursing -Note the client’s age, -This affect the client’s -NANDA nursing
needs know if someone delusions. interventions, the gender, developmental ability to protect self and 14th Edition interventions,
is talking to him patient will be able stage, decision-making others, and influence pg. 481 the patient will
Maslow’s second and sometimes, he to: ability, and level of choice of interventions be able to:
tier of safety always talks about cognition. and teaching,
the RED KNIGHT • Be free from injury.
Maslow’s third tier he always sees” as -Evaluate the -This may affect the -NANDA •Be free from
of belonging verbalized by his individual’s emotional client’s view of and regard 14th Edition injury.
friend Jack. and behavioral response for own/other’s safety. pg. 481
Maslow’s fourth to violence in #GOAL MET
tier of self-worth Objective: environmental
• Inappropriate surroundings.
Maslow’s fifth tier behavior
of achieving • Extreme -Observe for signs of -To determine need for -NANDA
potential preoccupation injury and age. evaluation of intentional 14TH Edition
with the religion. injury or abuse in client pg. 481
Uninhibited relationship and living
actions environment.
•Hallucination DEPENDENT
• Change in
personality - Avoid use of restraints. - If patients are -NANDA
• Feelings of Obtain a physician’s restrained, they can 14TH Edition
indifference order if restraints are sustain injuries, including pg. 482
• Inability to needed. head injury from leading
concentrate with their heads to get out
of the bed.
-Administer medications -To prevent any action -NANDA
and infusions using 6 that might cause injury to 14TH Edition
rights system. the patient. pg. 482

COLLABORATIVE
-Refer to physical or -To identify high-risk -NANDA
occupational therapist or tasks and provide 14th Edition
psychologist as education about how to pg. 483
appropriate. avoid injury.

-Encourage participation -To enhance self-esteem -NANDA

in self-help programs, and sense of self-worth. 14th
such as assertiveness Edition pg.
training, positive self- 483
image.

-Refer to other -Counseling is one of the -NANDA

resources, as indicated. resources a nurse can 14th
refer for the patient. Edition pg.
483