SOUTHERN ILLINOIS UNIVERSITY
SCHOOL OF NURSING
GUIDE FOR NURSING CARE PLANS
Assessment Factors & Nursing Diagnosis:
| Setting | Identify the setting where the care is being given:
hospital, long term care facility, home, clinic etc. |
| Assessment Data | Significant Data from Assessment used to
validate the diagnosis including admitting symptoms and medications. Health history,
mental status, physical findings, behavior, and patient’s statements may also be
included. |
| Nursing Diagnosis | Use NANDA format: e.g., Visual sensory/perpetual
alterations related to changes in dopamine pathways and excessive stimulation as evidenced
by reported visual hallucinations. |
| Defining Characteristics: |
Observable signs and symptoms (Specific assessment data) |
| Related factors: | Factors thought to be related to or cause of the problem. Also, situations that will impact how the care is given. Can be physical, psychological, environmental, social or spiritual. |
Outcomes & Interventions:
| Expected Outcomes | Specific, observable, realistic and measurable goals.
(Include discharge expectations) |
| Ongoing Assessment | This includes the related factors and defining characteristics. |
Therapeutic Interventions
These are measures required to meet the outcomes. They usually begin with a verb and
include actual nursing therapies, documentation of actions and results, and consultation
and communication with other health professionals. Include rationale and theoretical
documentation for interventions.
Evaluation Data:
Discuss the outcome expectations and what happens if they are not met.
Revision of Outcomes & Interventions:
Indicate how plan and/or when plan will be revised.
SOUTHERN ILLINOIS UNIVERSITY
SCHOOL OF NURSING
NURSING CARE PLAN EXAMPLE
| Setting: | Inpatient psychiatric unit in a general hospital |
| Baseline Assessment: | 40 year old white female admitted to emergency room at 4:00 pm after being preoccupied with suicide thoughts of jumping off a bridge. Divorce was final last week and she lost her job this week. She has a history repeated bouts of depression and numerous suicide attempts, usually by medication overdose. Her mood is extremely depressed and keeps repeating that there is no hope for her life. |
Associated Psychiatric Diagnosis:
| Axis I | Major Depressive Disorder, Recurrent |
| Axis II | Borderline Personality Disorder |
| Axis III | Diabetes Mellitus, insulin dependent Obesity |
| Axis IV | Problems with Primary Support Group (recently divorced) Economic Problems (loss job) |
| Axis V | GAF =75 |
Medications
Lithium Carbonate 300 mg b.i.d.
Zoloft 150 mg PO qd
Insulin NPH 40 units in AM
Insulin NPH 20 units at HS
| Nursing Diagnosis 1: | Violence, high risk for self-directed related to suicide ideation as evidenced by verbalization of constantly thinking of jumping off a bridge, sleep pattern changes, hopelessness and lack of impulse control. |
Defining Characteristics
Constant thoughts of wanting to kill self
Lack of impulse control
Believes she has nothing to live for
Verbalizes hopelessness
Believes she no friends since she lost her job
Wakes up in early morning thinking about ending it all
Believes she is a failure
Related Factors
Social isolation, lives alone (only daughter recently moved out to
live with boyfriend)
Has attempted suicide in the past
Ex-husband plans to remarry
Depression has been difficult to treat and required numerous medication changes.
OUTCOMES
Initial
1. Not harm self.
2. Identify antecedents to suicide impulse.
3. Develop a contract with nurse not to hurt self.
Discharge
4. Identify ways of dealing with suicidal impulses if they return.
5. Demonstrate use of alternative ways of dealing with
stress and emotional problems.
6. Identify therapist to help on a long term basis.
INTERVENTIONS
| Interventions | Rationale | Ongoing Assessment |
| Suicide Precautions based upon assessment and hospital policy. One-to-one observation first 24 hours | Protect from self-harm by close observation. Approximately 5-6% of the suicides occur in the hospital. Level of observations should be least restrictive (citation, 19xx). | Determine if patient has intent to harm self. Identify whether there is a plan and whether means available. |
| Formulate a no-suicide verbal contract within first 24 hours. | Research supports the effectiveness of a verbal contract in preventing suicide(citation, 19xx). | Determine whether or not patient is able to keep contract. |
| Initiate written no suicide contract within first 24 hours | Continue as appropriate |
EVALUATION
| Outcomes | Revised Outcomes | Interventions |
| Has not harmed self and is no longer verbalizing suicidal thoughts. | Will not attempt to harm self as level of observation is reduced. | Modified suicide precaution with close observation. |
| Has identified realization of living alone as antecedent to suicide thoughts. | Explore meaning of living alone and how to feel safe at home. | Use therapeutic relationship as a tool to clarify meaning of living alone and to problem solve ways of dealing with loneliness. |
| Agreed to no-suicide contract and has been verbalizing success in keeping it. | Maintain a contract with nurse while in hospital. | Continue to discuss contract with patient. |
| Continue with rest of outcomes. |
|
Refer to unit 3 in text for instructions in nursing care planning.