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Nursing Station Care Plans

Alteration in Family Processes

Alteration in Family Processes (_)Actual (_) Potential Related To: (_) Illness of a family member:_____________________ (_) Loss/gain of family member due to:______________ ____________________________________________ (_) Change in family roles:_______________________ (_) Conflict:___________________________________ (_) Financial crisis:_____________________________ (_) Other:____________________________________ ____________________________________________ ____________________________________________   As evidenced by: Major: (Must be present) (_) ... Find out more

Alteration in Health Maintenance Ca...

Alteration in Health Maintenance (_)Actual (_) Potential Related To: (_) Loss of independence (_) Changing support systems (_) Change in finances (_) Lack of knowledge (_) Poor learning skills (illiteracy) (_) Crisis situation (_) Inadequate health practice (_) Substance abuses:_______ __________________________ (_) ... Find out more

Alteration in Nurtition: More Than ...

Alteration in Nurtition: More Than Body Requirements (_)Actual (_) Potential Related To: (_) Altered satiety patterns (_) Medications (steroids) (_) Lack of knowledge (_) Decreased activity (_) Decreased metabolic needs (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Overweight (weigh ... Find out more

Alteration in Nutrition: Less Than ...

Alteration in Nutrition: Less Than Body Requirements (_)Actual (_) Potential Related To: (_) Dysphagia caused by:_________________ (_) Absorptive disorders (_) Anorexia (_) Allergy (_) Burns (_) Cancer (_) Chemotherapy (_) Chemical dependence (_) Crash or fad diet (_) Depression (_) Inability to obtain ... Find out more

Alteration in Parenting

Alteration in Parenting (_)Actual (_) Potential Related To: (_) Abusive (_) Accident victim (_) Acutely disabled (_) Addicted to drugs (_) Adolescent (_) Alcoholic (_) Breastfeeding difficulties (_) Change in family unit (_) Economic problems (_) Emotionally disturbed (_) Lack of extended family (_) ... Find out more

Alteration in Patterns of Urinary E...

Alteration in Patterns of Urinary Elimination: Incontinence (_)Actual (_) Potential Related To: (_) Congenital urinary tract anomalies: ________________________________ (_) Disorders of urinary tract:_________ ________________________________ (_) Drug therapy (_) Environmental barriers to bathroom (_) Estrogen deficiency (_) Inability to communicate needs (_) ... Find out more

Alteration in Patterns of Urinary E...

Alteration in Patterns of Urinary Elimination: Retention (_)Actual (_) Potential Related To: (_) Anxiety (_) Fecal impaction (_) Flaccid bladder (_) Medications (_) Packing (_) Stones (_) Weak or absent sensory and/or motor impulses (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) ... Find out more

Alteration in Sensory Perceptual Ca...

Alteration in Sensory Perceptual (_)Actual (_) Potential Related To: (_) Amputation (_) Bedrest (_) Cast (_) Hearing (_) Immobility (_) Impaired oxygen transport (_) Medications (_) Metabolic alterations (_) Neurological alterations (_) Pain (_) Paraplegia (_) Physical isolation (_) Social isolation (_) Stress (_) Traction (_) Visual (_) Other:_____________________________ ____________________________________ ____________________________________   As ... Find out more

Alteration in Thought Processes

Alteration in Thought Processes (Geriatrics) (_)Actual (_) Potential Related To: (_) Factors associated with aging. (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Inaccurate interpretation of stimuli, internal and/or external. Minor: (May be present) (_) Cognitive defects, including ... Find out more

Alterations in Cardiac Output: Decr...

Alterations in Cardiac Output: Decreased (_)Actual (_) Potential Related To: (_) Cardiac factors (_) Pulmonary disorders (_) Endocrine disorders (_) Hematological disorders (_) Fluid & electrolyte disturbances (_) Surgery/anesthesia (_) Newborn/Infant (_) Vagal stimulation (_) Stress (_) Shock (_) Allergic response (_) Medications (_) Other:___________________ ___________________________ ___________________________   As ... Find out more

Altered Growth and Development Care...

Altered Growth and Development Published on Saturday March 10th , 2007 Altered Growth and Development (_)Actual (_) Potential Related To: (_) Acute illness (_) Prolonged pain (_) Chronic illness (_) Prolonged bedrest (_) Neglect/isolation (_) Traction or casts (_) Separation from ... Find out more

Altered Oral Mucous Membranes: Stom...

Altered Oral Mucous Membranes: Stomatitis (_)Actual (_) Potential Related To: (_) Immunosupression from chemotherapy (_) Nutritional depletion (_) Radiation to head and neck (_) Improper fitting dentures (_) Excessive dry mouth (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Disruption ... Find out more

Altered Sexuality Patterns Care Pla...

Altered Sexuality Patterns (_)Actual (_) Potential Related To: (_) Cardiac disease (_) Chronich respiratory disease (_) Medication (_) Metabolic disease (_) Neurological disease (_) Penile prosthesis (_) Prostatectomy (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Identification of sexual difficulties, limitations, or ... Find out more

Anxiety Care Plan

Anxiety (_)Actual (_) Potential Related To: (_) Anesthesia (_) Anticipated/actual pain (_) Disease (_) Invasive/noninvasive procedure:_________ _____________________________________ (_) Loss of significant other (_) Threat to self-concept (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Elevated BP, P, R (_) Insomnia (_) Restlessnes ... Find out more

Comfort: Chest Pain Care Plan

Comfort: Chest Pain   Related To: (_) Myocardial Infarction (_) Unstable Angina (_) Coronary Artery Disease (_) Chest Trauma (_) Stress Anxiety (_) Musculoskeletal Disorders (_) Pulmonary, Myocardial contusion (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Person reports or demonstrates a ... Find out more

Discharge Care Plan

Discharge Care Plan Date & Sign. Plan and Outcome Target Date: Nursing Interventions Date Achieved:   (_) The patient/family's discharge planning will begin on day of admission including preparation for education and/or equipment.(_) On the day of discharge, patient/family will ... Find out more

Disuse Syndrome Care Plan

Disuse Syndrome (_)Actual (_) Potential Related To: (_) Unconciousness (_) Neuromuscular Impairment (_) Musculoskeletal condition (_) Immobility (_) Traction/casts/splints (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Presence of risk factors. (See above "Related To").   Date & Sign. Plan and Outcome Target Date: Nursing Interventions Date Achieved:   The patient ... Find out more

Diversional Activity Deficit Care P...

Diversional Activity Deficit (_)Actual (_) Potential Related To: (_) Monotonous environment (_) Long-term hospitalization (_) Lack of motivation with signs of depression (_) Skeletal-muscular impairments (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Observed statement of boredom/depression fro inactivity. Minor: (May ... Find out more

Fluid Volume Deficit Care Plan

Fluid Volume Deficit (_)Actual (_) Potential Related To: (_) Excessive urinary output. (_) Inadequate fluid intake. (_) Abnormal drainage. (_) Excessive emesis. (_) Difficulty in swallowing. (_) Medication:________________________ (_) Diarrhea (_) Shock (_) Hemorrhage (_) Fever (_) Burns (_) Other:_____________________________ ____________________________________ ____________________________________   As ... Find out more

Fluid Volume Excess Care Plan

Fluid Volume Excess (_)Actual (_) Potential Related To: (_) Decreased cardiac output (_) Low protein intake (_) Liver disease (_) Inflammatory process (_) Steroid therapy (_) Medications:_______________________ (_) Excess fluid intake (_) Sodium intake more than adequate (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must ... Find out more

Greiving Care Plan

Greiving (_)Actual (_) Potential Related To: (_) Loss of function of body part:__________________________________ (_) Loss of s/o:________________________________________________ (_) Loss of independence/change in lifestyle. (_) Diagnosis of a terminal illness. (_) Loss of physical abilities:_____________________________________ (_) Other:____________________________________________________ ____________________________________________________________ ____________________________________________________________   As evidenced by: Major: (Must ... Find out more

Hyperthermia Care Plan

Hyperthermia (_)Actual (_) Potential Related To: (_) CNS Pathology (_) Dehydration (_) Exposure to heat/sun (_) Impaired physical environment (_) Infection (_) Inflammation (_) Peripheral neuropathy related to injury (_) Vigorous activity Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Temperature over ... Find out more

Hypothermia Care Plan

Hypothermia (_)Actual (_) Potential Related To: (_) CNS pathology (_) Decreased ability to shiver (_) Exposure to the cold (_) Impaired physical environment (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Reduction in body temperature below 35 C (95 ... Find out more

Impaired Adjustment Care Plan

Impaired Adjustment (_)Actual (_) Potential Related To: (_) Illness (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Verbalization of non-acceptance of health status change. (_) Inability to be involved in problem solving or goal setting. Minor: (May be present) (_) ... Find out more

Impaired Gas Exchange Care Plan

Impaired Gas Exchange (_)Actual (_) Potential Related To: (_) Anesthesia (_) Allergic response (_) Altered level of consciousness (_) Anxiety (_) Aspiration (_) Decreased lung compliance (_) Edema of tonsils, adenoids, sinuses (_) Excessive or thick secretions (_) Fear (_) Immobility (_) Improper ... Find out more

Impaired Home Maintenance Managemen...

Impaired Home Maintenance Management (_)Actual (_) Potential Related To: Chronic debilitating disease: (_) Arthritis (_) Cancer (_) CHF (_) COPD (_) Diabetes mellitus (_) Multiple sclerosis (_) Muscular dystrophy Injury to individual or family members: (_) Addition of family member (_) Loss of ... Find out more

Impaired Physical Mobility Care Pla...

Impaired Physical Mobility (_)Actual (_) Potential Related To: (_) Amputation (_) Cardiovascular (_) External devices (_) Impaired balance (_) Limited ROM (_) Musculoskeletal impairment (_) Neuromuscular impairment (_) Pain (_) Surgical procedure (_) Trauma (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Inability to move ... Find out more

Impaired Skin Integrity Care Plan

Impaired Skin Integrity (_)Actual (_) Potential Related To: (_) Burns of_______________________ (_) Decreased sensation (_) Immobility (_) Malnutrition (_) Pressure ulcer (_) Puritus (_) Stoma problems (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Disruption of epidermal and dermal tissue. Minor: (May be present) (_) ... Find out more

Impaired Social Interaction Care Pl...

Impaired Social Interaction (_)Actual (_) Potential Related To: (_) Mental illness (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Reports inability to establish and/or maintain stable, supportive relationships. Minor: (May be present) (_) Lack of motivation. (_) Sever anxiety. (_) ... Find out more

Impaired Verbal Communication Care ...

Impaired Verbal Communication (_)Actual (_) Potential Related To: (_) Auditory impairment (_) Cerebral impairment (_) Fear/shyness (_) Lack of privacy (_) Lack of support system (_) Language barrier (_) Laryngeal edema/infection (_) Neurologic impairment (_) Oral deformities (_) Pain (_) Respiratory impairment (_) Speech ... Find out more

Ineffective Airway Clearance Care P...

Ineffective Airway Clearance (_)Actual (_) Potential Related To: (_) Atrificial airway (_) Excessive or thick secretions (_) Inability to cough effectively (_) Infection (_) Obstruction/restriction (_) Pain (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Ineffective cough. (_) Inability to remove airway ... Find out more

Ineffective Breathing Patterns Care...

Ineffective Breathing Patterns (_)Actual (_) Potential Related To: (_) Allergic response (_) Anesthesia (_) Aspiration (_) COPD (_) Decreased lung compliance (_) Fatigue (_) History of smoking (_) Immobility (_) Medications (narcotics, sedatives, analgesics) (_) Neuromuscular impairment (eg. MS, Guillain-Barre) (_) Surgery or ... Find out more

Ineffective Individual Coping care ...

Ineffective Individual Coping (_)Actual (_) Potential Related To: (_) Illenss:____________________________ ____________________________________ (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Change in usual communication patterns (in acute). (_) Verbalization of inability to cope. (_) Inappropriate use of defense mechanisms. (_) Inability ... Find out more

Knowledge Deficit care plan

Knowledge Deficit (_)Actual (_) Potential Related To: (_) New diagnosis:_____________________________ (_) Language differences:________________________ (_) Hospitalization (_) Diagnostic test:_____________________________ (_) Surgical procedure:__________________________ (_) Medications:_______________________________ (_) Pregnancy (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Verbalizes a deficiency in knowledge or skill. (_) Requests ... Find out more

Noncompliance care plan

Noncompliance (_) Exercise (_) Follow-up Care (_) Medication (_) Other Related To: (_) Chronic illness (_) Fatigue (_) Depression (_) Non supportive family (_) Inadequate/incomplete instructions (_) Denial of Dx (_) Side effects of therapy/med (_) Impaired ability to perform ... Find out more

Potential for Infection

Potential for Infection (_)Actual (_) Potential Related To: (_) Alteration in skin integrity:___________________________ __________________________________________________ (_) Bone marrow depression. (_) Indwelling catheter:________________________________ (_) Nutritional deficiencies:______________________________ __________________________________________________ (_) Surgical/invasive procedures:________________________ __________________________________________________ (_) Other:__________________________________________ _________________________________________________ __________________________________________________   As evidenced by: Major: (Must be present) (_) Altered production of leukocytes. (_) Altered immune ... Find out more

Powerlessness

Powerlessness (_)Actual (_) Potential Related To: (_) Inability to communicate:________________________ (_) Inability to perform ADL:________________________ (_) Inability to perform role responsibilities:_____________ ______________________________________________ (_) Progressive debilitating disease:_________________ (_) Hospital or institutional limitations:_________________ ______________________________________________ (_) Other:______________________________________ ______________________________________________ ______________________________________________   As evidenced by: Major: (Must be present) (_) Overt or ... Find out more

Rape Trauma Syndrome

Rape Trauma Syndrome (_)Actual (_) Potential Related To: Somatic Response: (_) Gastrointestinal irritability (N/V, anorexia) (_) Genitourinary discomfort (pain, puritus) (_) Skeletal muscle tension (spasm, pain) (_) Other:___________________________ ___________________________________ Sexual responses: (_) Mistrust of men (if victim is woman) (_) Change ... Find out more

Self Care Deficit: Bathing

Self Care Deficit: Bathing (_)Actual (_) Potential Related To: (_) Neuromuscular impairment (_) Visual disorders (_) Trauma or surgical procedure (_) External devices (_) Aging process (_) Musculoskeletal disorders (_) Immobility (_) Nonfuntioning or missing limbs (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be ... Find out more

Self Care Deficit: Dressing and Gro...

Self Care Deficit: Dressing and Grooming (_)Actual (_) Potential Related To: (_) Neuromuscular impaitment:___________________________ (_) Impaired visual actuity (_) Immobility (_) Weakness (_) Decreased level of consciousness (_) Other:___________________________________________ ___________________________________________________ ___________________________________________________   As evidenced by: Major: (Must be present) (_) Impaired ability to put on ... Find out more

Sleep Pattern Disturbance

Sleep Pattern Disturbance (_)Actual (_) Potential Related To: (_) Impaired oxygen transport (_) Impaired elimination (_) Impaired metabolism (_) Immobility (_) Medication (_) Hospitalization (_) Lack of exercise (_) Anxiety response (_) Life-style disruptions (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Difficulty falling ... Find out more

Social Isolation

Social Isolation (_)Actual (_) Potential   Related To: (_) Death of s/o (_) Divorce (_) Substance abuse (_) Illness:____________________________ ____________________________________ (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Expressed feelings of unexplained dread or abandonment (_) Desire for more contact with people Minor: (May ... Find out more

Spiritual Distress

Spiritual Distress (_)Actual (_) Potential Related To: (_) Pain (_) Trauma (_) Loss of body part/function (_) Terminal illness (_) Death of s/o (_) Unable to practice religious rituals (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) Experiences a disturbance in ... Find out more

Violence

Violence (_)Actual (_) Potential Related To: (_) Acute agitation (_) Poor impluse coordination (_) Mania (_) Feelings of helplessness (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) History of harm to others (_) Destruction of property (_) Overt aggressive acts Minor: (May ... Find out more

Alteration in Bowel Elimination: Di...

Alteration in Bowel Elimination: Diarrhea (_)Actual (_) Potential Related To: (_) Inflammation of bowels (_) Colon mucosa ulceration (_) Fecal impaction (_) Gastric bypass (_) Infant - breast fed (_) Decreased sphincter reflexes (_) Allergies (_) Medications_______________________ ____________________________________ (_) Stress/anxiety (_) Tube feedings (_) ... Find out more

Alteration in Bowel Elimination: Co...

Alteration in Bowel Elimination: Constipation (_)Actual (_) Potential Related To: (_) Malnutrition (_) Metabolic and endocrine disorders (_) Sensory/motor disorders (_) Stress (_) Immobility (_) Inadequate diet (_) Irregular evacuation pattern (_) Drug side effects (_) Pain (upon defecation) (_) Pregnancy (_) Surgery (_) ... Find out more

Activity Intolerance

Activity Intolerance (_)Actual (_) Potential Related To: (_) Alterations in O2 transport (_) Chronic disease:____________ ____________________________ (_) Depression (_) Diabetes Mellitus (_) Fatigue (_) Lack of motivation (_) Malnourishment (_) Pain (_) Prolonged immobility (_) Stressors (_) Other:_____________________________ ____________________________________ ____________________________________   As evidenced by: Major: (Must be present) (_) _____________________________________________________ ________________________________________________________ ________________________________________________________   Date & Sign. Plan ... Find out more

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