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Bishwajit
Mazumder
Nursing Instructor
Dhaka Nursing College, Dhaka
E. mail: mbishwa@rocketmail.com
NURSING CARE PLAN
Background:
The Florence Nightingale is the founder of nursing. She was born on 12 May
1820 and died 1910, and named after the Italian city of her birth. She is the person, who
created and develop nursing care plan also proved it. In 1854, at the time of Crimean War
she applied her care with affected soldiers and able to dramatically reduced mortality
rates from 40% to 2% (Florence Nightingale International Foundation (FNIF) Copying,
1999 - 2013). Now a day, there are many theorist/Author makes different strategies of
nursing care plan.
Nursing care plan is a strategy or design or guide for health care professionals.
Care plans are intended to ensure optimal outcomes for patients during the course of the
care (Mosby's Dental Dictionary, 2nd edition. 2008). This is the way of conceptualizing
and organizing the knowledge, skills, values and beliefs critical to the design of a
coherent curriculum that facilitates student learning and their achievement of the desired
educational outcomes. Curriculum remains dynamic, especially as education faces the
challenges of an exponential growth in knowledge, how to learn and the evolving and
uncertain future of the health industry (Forbes & Hickey, 2009). A care plan is an
agreement between you and your health professional (and/or social services) to help you
manage your health day-to-day. It can be a written document or something recorded in
your patient notes (www.nhs.uk).

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Nursing care is the vital part of the nursing. This is very important; because,
caring outcome depend on effective nursing care plan. It can conduct for effective plan by
seminar, discussion, training program and so on. Nursing care plan is very effective
education learning. Learner can understand how to make a plan and how to implement it.

Underpinning principles:
1. Care plan influence to the student moves from the simple/basic aspects to the
complex aspects.
2. Nursing courses and between nursing and related science courses is planned to
correlate as much as possible.
3. It provides didactic instruction, skills laboratory and exercises, seminars, small
group discussions, and direct clinical practice.
4. It provides structuring learning by program design and consistent use of theory
and laboratory.
The Nursing Process
According to Roy Adaptation Model, the nursing process is a problem-solving
process that requires the use of decision-making, clinical judgment, and other critical
thinking skills to assess, identify and prioritize client problems, to assign nursing
diagnoses with measurable outcomes, to plan care systematically, and to implement and
evaluate the results of the care given.
The steps of the nursing process include:

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Assessment: This is the first step of nursing care process. According to Roy adaptation
model it discussed bellow.
Assessment of Behavior: The indicator of how a human adaptive system
manages to cope with, or adapt to, changes in health status is behavior. Thus, the first step
in the nursing process involves gathering data about the behavior of the human adaptive
system and the current state of adaptation by continuously gathering objective and
subjective information. This data is continuously updated, validated, and communicated.
Assessment of Stimuli: This is the second step of the nursing process which
involves the identification of internal and external stimuli that are influencing the
persons adaptive behaviors. Stimuli are classified as: 1) Focal- those most immediately
confronting the person; 2) Contextual-all other stimuli present that are affecting the
situation and, 3) Residual- those stimuli whose effect on the situation are unclear.
Nursing Diagnosis: Nursing diagnosis is a clinical judgment about individual, family, or
community responses to actual and potential health problems/life processes. Nursing
diagnoses provide the basis for selection of nursing interventions to achieve outcomes for
which the nurses accountable (Davise, 2003). This involves the formulation of statements
that interpret data about the adaptation status of the person, including the behavior and
most relevant stimuli. Data collected thus far in the nursing process take the form of
statements about the behavior of the human adaptive system that have been observed,
measured, or subjectively reported. The nursing diagnosis is an interpretive statement
about the human adaptive system. The nursing diagnosis is defined by RAM as a
judgment process resulting in statements conveying the adaptation status of the human
adaptive system and is used to set patient goals of adaptation.
Planning: The third step of the nursing process involves the establishment of clear
statements of the behavioral outcomes for nursing care. The nurse establishes these client
goals/outcomes and works with the client to promote adaptation. Goal setting influence

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the behavioral outcome that will promote adaptation. The goal not only change behavior
to be observed but the way of behavior change (as observed, measured or subjective
repotted) and the time from in which the goal is to be attained (Roy, 2009, p. 77).
Implementation: The implementation of care best assists the person in attaining
established outcomes. In this phase nurse takes a decision and identification of possible
approach to nursing intervention. Appropriate nursing intervention can alter the stimulus
and enhance coping (Roy, 2009, p. 80).
Evaluation: The final step in the nursing process involves evaluating the effectiveness of
the nursing intervention by comparing the behavior after the nursing intervention and the
established goal. Together, the nurse and client identify factors that either positively or
negatively influenced goal/outcome achievement. Client response to the plan of care
determines whether nursing care should be continued as is, modified, or terminated. If
evaluation points to the need to modify the nursing care plan, then the accuracy,
completeness, and relevance of the assessment data, as well as the appropriateness of
client diagnoses, goals, and nursing interventions, should all be carefully reviewed and
modified. During this step of the nursing process the nurse compares actual outcomes
with expected outcomes of care and reprioritizes client goals as indicated.
Example of Nursing Care Plan:
Case study:
A 75 years old Buddhist woman; lives in the North-East in the pechboon province
in Thailand. She is a lottery sales woman. She admitted on August 15th, 2013 in Chonburi
hospital. Her cheap complain was cough and dyspnoea and medical diagnosis
hypertension with asthma.
The client has been suffering from asthma for 3-4 years. When she first admitted
in hospital, that time medical diagnosis was Asthma with HTN and still now she follows
medical treatment. According to doctor prescribes, she uses inhaler (bronchodilator and

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steroid), tab-sulbutamol and anti hypertensive drug. She visits with the doctor every two
month interval. Two days before admission she went to the doctor for regular visits. The
doctor prescribed liquid cough expectorant; however, there was no improved her
condition. So she admitted in this hospital for better management. During admission she
was suffering from dyspnoea and cough.
She is admitted to hospital in severe time with dyspnoea and cough, around 2-3
times in a month. When she cooks, cooking smoke affect her problem. Also air pollution /
weather sometimes increase her dyspnoea. She feels discomfort and cannot sleep well
due to fear of death. It was interestingly that, during discharged she was very anxious,
worry about her business (lottery).
Vital sign: PR=99bpm, RR=26bpm, BP=145/95mmofHg.
Case summary:
The client cannot take care her health and cannot appropriately use of inhaler;
because, she is frequently admitted to the hospital. She feels discomfort, fear, anxiety and
cannot sleep well due to death. Some factors are affect dyspnoea such as cocking smoke,
Air pollution and bad weather. It was very interesting that; during her discharged, she
worried about her lottery more than her diseases.
Concept mapping of dyspnoea with Asthma:

Asthma

Cooking
smoke
Air pollution

Fear
Dyspnoe
a
Insomnia

Anxiety

Lottery
(Business)

Frequent to
hospital

Need more
money
Loss of

List of problem: According to priority of the problem

1. Dyspnoea
2. Dyspnoea and anxiety related to lottery.
Nursing care plan:
Assessment:
Data support
Subjective data: Patient cannot sleep well, anxious, worried about her business
and feels discomfort.
Objective data: Patient appearance ill and pale, PR=99bpm, BP=119/55mmofHg,
RR=26bpm level of dyspnoea score 10 and anxiety score 09 (measurement by visual
analog scale, the scale has 0-10 score. 0=no dyspnoea, 10=severe dyspnoea).
Diagnosis:
1. Dyspnoea in Asthma
2. Dyspnoea and anxiety related to lottery in Asthma patient.
Goal setting:
1. To reduce Dyspnoea in Asthma
2. To reduce Dyspnoea and anxiety related to lottery in Asthma patient
Expected outcome:
1. Level of dyspnoea score 04 (measurement by visual analog scale).
2. Level of Anxiety score 05 (measurement by visual analog).
3. Pulse rate -72bpm, BP-120/80mmof Hg.
Intervention:

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Pharmacological Intervention:
In this intervention nurse should be carefully manage to the patient. As a nurse
should be remind right time, right dose, right medicine, right patient and right way. Also
makes good interpersonal relationship and trust worthiness between nurse and patient.
1.
2.
3.
4.

Use bronchodilator as per doctor order.

Use Steroid drug according to doctor order.
Infusion (if dehydration). According to doctor order.
Nebulization ( if needed)

Non pharmacological:
1. Assessed the vital signs and record 4 hourly then PR, RR 1 hourly
2. Clearance the airway and suctioning the patients with maintenance aseptic
3.
4.
5.
6.
7.

precaution if needed to the patient.

Propped up position and oxygen inhalation (02saturation).
Observed and checked respiratory status hourly.
Monitor 02sat 100%.
Close monitor to the patient.
Record intake and output chart.

Massage Therapy:
Massage therapy is important for reduce anxiety. Nurse applies this technique in
hospitalized patient. Firstly, make trustworthiness and good understanding with the client.
After that, take to provide about this technique. Secondly; getting permission to the client
then it will apply. It can be head, back, arm and foot massage. Also nurse can counsel to
the family care givers, how to give massage therapy at their home to the client.
Evaluation of testing intervention:
S/No

Indicators

Case
Before Intervention

After Intervention

Dyspnoea

10

04

Score
Anxiety

09

05

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4

Score
PR

99bpm

72bpm

RR

26bpm

22bpm

Outcomes: After pharmacological and non-pharmacological intervention, it is found that

dyspnoea score 04 and anxiety score 05 (used by visual analog scale), pulse rate 72bpm,
and respiration rate 22bpm.
Advantages of a care plan:
1.

Helps a student to develop skills in solving health related problems

2. Promotes self directed learning and spirit of enquiry

3. Provokes a sense of critical thinking and reasoning
4. Retention and application of knowledge is reinforced in a similar way to that
in the clinical context
5.

Develops integrated body of knowledge based on real and common situation.

(McKimm, 2007)

Disadvantages of care planning:

1.
2.
3.
4.
5.

Planning has tendency to make administration inflexible.

There is no scope for individual freedom.
Planning is a time consuming process.
This is not suitable during emergency or crisis when quick decisions are required.
It does not always reflect real situations.
(Management study guide, 2013)

Advice to the client:

1.
2.
3.
4.

Inhaler or antihypertensive drug should be kept with your-self all-time.

You should kept asthma guide line and follow it.
You should kept hand book or doctor prescription.
You should take regular doctor visit (according to prescribe).

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5. Use musk so that you can protect any smoke and polluted air.
6. You should avoid cold drinking.
References:
Management study guide.com. opyright 2008 - 2013 All rights reserved.
http://www.managementstudyguide.com
Mosby's Dental Dictionary, 2nd edition. 2008 Elsevier, Inc. All rights reserved.
McKimm J, (2007). Curriculum design and development
Piper B, RN, MN. Interim Nursing Director, (253) 864-3111.www.nlnac.org
Roy, Sr,C. (2009). The Roy adaptation model (3rd ed). Upper saddle River,
NJ:person.
http://www.nhs.uk/Planners/Yourhealth/Pages/Careplan.aspx