Running head: NURSING PROCESS AND CARE PLAN

Nursing Process and Care Plan

Truc La
NFDN 1001 Assignment 2
NorQuest College
Cindy Hoyme
June 11, 2015

NURSING PROCESS AND CARE PLAN

Step 1: Nursing Assessment Form

Client Name:

Anna Lee

Medical Diagnosis: Asthma

Client Perception of Health Needs: Anxiety

Client Goals for Health: N/A
Allergies
(food,
medication,
environmental)

Food: Shellfish

Medications

Ventolin puffers occasionally when needed.

Medication: N/A
Environment: N/A

Dietary
Eating pizza and coffee to keep herself going
considerations

HEALTH ASSESSMENT DATA

Fill in data from the scenario
Client
The client is a female.

She is 19 years old and living with her boyfriend in Alberta.

She is living away from her parent and her two younger sibling. Her family remains in
New Brunswick.
She is a student in the Practical Nurse program and works part-time at Sportcheck.
She is also taking English course one evening a week.
Anna is working three 12 hour shifts in the clinical.
Anna is allergic to shellfish.

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HEALTH ASSESSMENT DATA

Health
Anna is allergic to shellfish.

She has been diagnosed with Asthma as a child and uses Ventolin puffers occasionally
when needed.
She is eating unhealthy foods such as pizza and coffee.
She takes no other regularly scheduled medication.
The boyfriend is pressuring her to spend more time with him.
The client does not have enough sleep because she has been up several nights trying to
complete a scholarly paper.
The client is finding it difficult to juggle all of the responsibilities and is feeling very
anxious.
Spiritual Variable (Environment)

Developmental Variable (Environment)

Anna celebrates Christmas because she wants

She is 19 years old and has a boyfriend.

to buy gifts for her friends and family.

According to Potter et al., (2014), in

Ericksons theory stage, the client is at stage 6
which is Intimacy versus Isolation.
Anna is working and studying at the same
time. She is a student in the Practical Nurse
and works part-time at Sportcheck.

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HEALTH ASSESSMENT DATA

Sociological Variable (Environment)

Psychological Variable (Environment)

Anna is living with her boyfriend in Alberta.

Anna has one month left to complete her

Her parent and two younger sibling are living

course work, studies for finals, buys Christmas

in New Brunswick.

gifts for friends and family. She is having

She is a student in the Practical Nurse

difficulty maintaining her part-time job while

program and often spends time with her peers

she is doing clinical setting.

for group studying.

Annas boyfriend is pressuring her to spend

Anna asks the college tutor to help with her

more time with him. Anna is finding her

scholarly paper.

situation difficult to juggle all of these

Anna speaks with her instructor at school to

responsibility and feeling very anxious.

get some advices about eat healthy in student

budget.

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HEALTH ASSESSMENT DATA

Determinants of health impacting clients health (Environment)
Social environment:
+ The client is a student and lives with her boyfriend in Alberta. Her parent and two younger
siblings are living in New Brunswick, so she is living far from her family.
+ Annas boyfriend is pressuring her to spend more time with him.
+ Anna studies with her peers as a group and asks tutor from the college to help with
scholarly paper.
+ Anna gets some advices from her instructor to eat healthy on a student budget.
Physical environment:
+ Anna is living on a tight budget, so it is very hard for her to have a good nutrient foods.
+ Anna is working part-time at Sportcheck and doing three 12 hr shifts in the clinical setting.
Additionally, she is taking another English course once evening a week, so she does not have
time to rest and sleep.
Health Priorities as determined by the Nurse and Client
Anxiety

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HEALTH ASSESSMENT DATA

Client Strengths as determined by the Nurse and Client
Anna is a hard working person and love to study.
Anna is taking medication for her Asthma when needed. Additionally, Anna does not take
any other medication.
Anna talks to her instructor to get some advices about eating healthy foods on student
budget.
The client is living with her boyfriend.

Step 2: Nursing Diagnosis

Write three (3) nursing diagnoses one actual, one potential, and one wellness behaviour that
include the following:
NANDA approved nursing diagnosis statement - Reference to a client strength or health

need

Cause/ Contributing factors (related to)

Symptom/ Presenting evidence (as evidenced by)

Actual Nursing Diagnosis

Anxiety related to imbalance time management as evidenced by studying for final exam,
wanting to buy Christmas gifts for friends and family, working part-time at Sportcheck,
studying an English course one a week, staying up several night to do homework, pressuring
from her boyfriend.

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Potential Nursing Diagnosis

Risk for fluid volume deficit related to close contact with friends who are sick as evidenced by
spending the previous afternoon with her peers in study group, and two of her peers just called
in sick to clinical complaining of vomiting and diarrhea.
Wellness Nursing Diagnosis
Readiness for increased knowledge related to nutrient as evidenced by client indicating current
diet as pizza and coffee, and asking question regarding healthy eating on a student budget.

Step 3: Nursing Care Plan

Anxiety related to imbalance time management as evidenced by studying for final exa

Christmas gifts for friends and family, working part-time at Sportcheck, studying an E
PRIORITY NURSING

week, staying up several night to do homework, and pressuring from her boyfriend to

DIAGNOSIS

him.

The reason I chose anxiety as a priority nursing diagnosis because Potter et al., (2014
anxiety are one of the highest priority (p. 174).
CLIENT GOAL
Write one specific and
Anna will be free of anxiety in 1 month.
measurable client
behavioural response.
CLIENT-CENTRED

Specific: The client will report the level of anxiety is decreasing at least 50 percent at

OUTCOME

following the care plan.

Write statements in

Measurable: The client will report that she has at least 7 hours of sleep, makes a list a

measurable terms that

hours with her boyfriend.

support the goal by

Attainable: The client needs to have knowledge about the plan and how to follow it. A

using the

week, the client will demonstrate relief of anxiety by saying that the plan is helping h

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Realistic: The client will have enough time to sleep, study, and spent time with her bo
SMART criteria:

client needs to know that sleep, and talk with her boyfriend relates to her overall healt

Specific
Measurable
Attainable
Realistic
Time-based

Time-based: The client will report that the level of her anxiety will decrease by 50 pe
second week and free of anxiety in 1 month following the care plan.

IDENTIFY 3 NURSING

1) The nurse needs to ensure the

2) The nurse will guide the client

3) The n

INTERVENTIONS

client will have at least 7 hours to

how to set priorities job by making

the clien

Select nursing

sleep every night.

a list.

with her

or maintain health status

RATIONALE FOR

Sleeping is playing an important

The client needs to organize and

Talk or e

INTERVENTIONS

role in everybody health.

makes the list about her tasks, so

someone

Provide rationale for

From National Sleep Foundation,

she can set the highest priority.

are also

selection of nursing

in How much sleep do we really

According to Potter et al., (2014)

Universi

interventions and use

need? (2015) suggests that an adult

that it is very important to sort out

Centre, i

appropriate literature

needs 7 to 9 hours of sleep every

which piece of work is the most

(2014) s

important need to be done first, on

people y

interventions to meet the

goals set, and to change

such as text, articles, and night. According to Potter et al.,

internet sites to support

(2014) that insufficient sleep alters the other hand, some works are

family

internet sites to support

mood and decreases the ability to

necessary but can wait to be done

trust who

choices

concentrate, make decision, and

later.

just talki

participate in daily activities (p.

one is al

992). Additionally, when a person

better.

do not have enough sleep, that

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person will have a significant effect

on health: fatigue, lethargy, and
lack of motivation, reduced
creativity and problem-solving
skills, inability to cope with
stress, concentration and memory
problem, difficulty making
decision (Smith, M., Robinson, L.,
& Segal, R., June 2015).

According to Potter et al., (2014) suggest in evaluation should include the nursing act
and finding, and achievement of outcome.

Nursing action: Ask client to report level of anxiety every week and observe a clie
verbal behavior closely (Potter et al., 2014, p. 160).
EVALUATION

The client response and finding: After 1 month following the nursing care plan, Ann
Describe how you plan

feeling anxious; She looks well rest and relax during the conversation. According to P
to evaluate if the goal

nurse needs to compare the clients behavioral response and the physiological signs a
was met or not met.
to observe with those you actually observe in your evaluation (p. 197).

Achievement of outcome: An outcomes are statements of progressive, step-by-step

that must be achieved in order to accomplish the goal of care (Potter et al., 2014, p. 1
the client reports 100 percent free of anxiety.
The goal was met, therefore, no further nursing action required.

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Summary
Anna Lee is a LPN student, and works part-time at Sportcheck. She is very busy with her
life and looks like that she does not have enough time for her work, her study, her sleep, and her
boyfriend is pressuring her to spend time with him. As her friend I decide that I need to help her
by making a Nursing Process and Care Plan for Annas anxiety. In this paper, I will explain why
nursing process are important to complete, how metaparadigm concepts guide me through this
assessment, and SMART criteria benefited in developing goals or expected outcome. According
to Potter et al., (2014) that it is very important for the nurse to follow these steps in nursing
process which included five steps: assessment, diagnosis, plan, implementation, and evaluation
because each step have its own unique. The four metaparadigm concepts are client and person,
environment, health and nursing, these concept will help the nurse to find the balance between
the personal value and professional value.
The nursing process
Assessment
According to Potter et al., (2014) that assessment is the first step that the nurse need to
follow by gathering and analysis of information about the client (p. 154). In this situation, I
need to collect data and information from the scenario such as client information about allergies
(food, medication, dieting consideration), health related, spiritual variable, developmental
variable, sociological variable, and psychological variable.
Diagnosis
Nursing diagnosis is the second step that every nurse needs to follow. After gathering the
data and information in assessment step, the nurse will have enough information to make a
decision about the actual, potential, and wellness nursing diagnosis; therefore, from there, the

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nurse need to understand what is the cause or contributing factor, and find the evidence (Potter et
al., 2014). By following this step, I made decision that actual nursing diagnosis is anxiety,
potential nursing diagnosis is risk to fluid volume deficit, and wellness nursing diagnosis is
readiness for increased knowledge.
Plan
Planning is the third step, the nurse needs to have a good judgment to make a right
decision and chose the right care plan to help the client solves the problem (Potter et al., 2014).
In Annas situation, anxiety is the highest priority that needs to be treated. And in this step, the
nurse should use the SMART criteria which stand for specific, measurable, attainable, realistic,
and time-based to have a good expect outcome.
Implementation
Implementation is the time to put the plan in real life to see if it is really working for the
client or not, and during this step the nurse can reassessing the client, or reviewing and revising
the existing nursing care plan to fit the clients situation (Potter et al., 2014). Putting this step in
Annas problem, the nurse can see that Anna is willing to follow the care plan, and the care plan
is working in her situation.
Evaluation
Evaluation is the final step in nursing process. At this step, the nurse should able to see if
the plan is really working in resolving the clients problem or this problem required further
nursing action (Potter et al., 2014). In Annas situation, no further nursing action required
because she is able balance her time and look well rest.
Metaparadigm

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According to Potter et al., (2014) suggest the nurses are giving care to everybody in the
social, and the nurse need to understand how the client is influenced by the family and
community. Therefore, the nurses will have better idea about caring for the client. Applying this
knowledge to Annas situation, it helps me understand more about Annas anxiety.
Conclusion
Consequently, following all the step in nursing process is very important for the nurse to
help the clients resolve their problem. Every step or every process has a significant effect on the
clients situation. That is the reason why the nurse must carefully assess, diagnosis, plan,
implementation, and evaluation the client. Additionally, every nurse should have a good
understanding about the client behavior, environment, family, community to have a good expect
outcome.

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References

Anxiety and stress (May 20, 2014). Retrieved from University of Maryland Medical Centre:
http://www.umm.edu/health/medical/ency/articles/stress-and-anxiety
How much sleep do we really need? (2015). Retrieved from National Sleep Foundation:
http://www.sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need
Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A. M., Ross-kerr, J. C., Wood, M. J.,
Duggleby, W. (Eds.). (2014). Canadian fundamentals of nursing (5th ed.). Toronto, ON:
Mosby/Elsevier Canada
Smith, M., Robinson, L., & Segal, R. (June 2015). How much sleep do you need? Retrieved from
Helpguide.org: http://www.helpguide.org/articles/sleep/how-much-sleep-do-youneed.htm