Nursing Care Plans and the Use of Teaching Guides

1. The nurse plays a major role in two important concepts of healthcare.
   1. Health Promotion
   2. Disease Prevention
   3. Reasons to adopt these two concepts are:
      • More cost-effective
      • Increased client satisfaction
      • Faster recovery
   4. The prevention focus is addressed at three levels:
      1. Primary prevention is the prevention of the initial occurrence of disease or injury.
      2. Secondary prevention is the early identification and treatment of disease or injury.
      3. Tertiary prevention maximizes the recovery after an illness or injury.
2. The nurse is frequently responsible for initiating a client’s plan of care. It is important to understand the components of a care plan. They are as follows:
   1. Assessment
   2. Diagnosis (nursing)
   3. Determine outcomes (set goals or desired outcomes for the client)
   4. Plan interventions (actions to be taken)
   5. Give nursing care (interventions in action)
   6. Evaluate nursing care (evaluate the effectiveness of intervention and/or need to change plan).
   7. Document (this tracks the client’s condition and response, care provided, and effectiveness of any teaching given)
3. The nursing responsibilities in the plan of care are as follows:
   1. The use of a nursing diagnosis provides the basis on which to select and build nursing interventions or nursing care.
   2. Components of the nursing diagnosis are as follows:
      • Diagnostic label—problem
      • Etiology—cause or risk factor
      • Signs and symptoms—defining characteristics
4. Explain the use of nursing diagnoses.
   1. A nursing diagnosis describes a client’s response to disease or injury.
   2. The most used list has been created by NANDA.
   3. The medical diagnosis and nursing diagnosis are not the same.
   4. The medical diagnosis describes the actual disease or injury and can be found in the ICD-9-CM codes.
   5. The three types of nursing diagnosis are as follows:
      1. Actual problem
      2. Risk for problem
      3. Wellness issues

Resources

2005-2006 NANDA-I-Approved Nursing Diagnosis

North American Nursing Diagnosis Association
NANDA International
100 N 20th Street, 4th floor
Philadelphia, PA 19103
800-647-9002
E-mail: info@nanda.org
www.nanda.org/

References

Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care. St. Louis: Mosby Inc.
Canobbio, M. M. (2006). Mosby’s handbook of patient teaching. St. Louis: Mosby Inc.
Cohen, B. J., & Taylor, J. J. (2005). Memmler’s The Human Body in Health and Disease (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Hunt, R. (2005). Introduction to community-based nursing. Philadelphia: Lippincott Williams & Wilkins.
Perry, A., & Potter, P. (2006). Clinical nursing skills & technique. St. Louis: Mosby Inc.

Credits

Client Teaching Guides for Home Health Care, 2nd ed.
© 2008 Jones and Bartlett Publishers, Inc.
www.jbpub.com