NU211- Intro to Clinical Practice Care Plan Template

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATON EVALUATION Assessment Priority Nursing Diagnose Goals/Outcomes List at least 2 (must be SMART goals-one long term one short term for each diagnosis) Interventions to Implement-relate to numbered Outcome At least 3 for each goal (Must be SMART) Rationale Must use APA references and have at least two different sources Evaluation-relate to numbered Goal/Outcome Subjective: Patient states that he is unsure about how to change his appliance and care for his colostomy. He is worried about how he will be able to continue to work or do other daily activities with the ostomy. He has stated, “what if I am out to eat and my bag is full”, “what will my kids think about the colostomy”, “guess I will have to give up bowling league now” and “how can I have relations with my wife, she won’t Ineffective sexuality pattern related to body image post colostomy as evidenced by a statement made by patient, “how can I have relations with my wife, she won’t find me attractive with this.” Deficient knowledge related to colostomy care as evidenced by statements made patient stating he is unsure how to change his appliance and care for his colostomy and is unsure how he will Short term: Patient will state two strategies to help eliminate problems with colostomy during intercourse. Long term: Patient will state strategies used to help with his acceptance of altered body structure or functioning by next appointment. Short Term: Patient will demonstrate how to empty colostomy bag by end of shift. Long Term: Patient will be able to explain how to incorporate new health regimen into life style by next Short term intervention 1: Nurse will help patient prepare significant others for physical and emotional changes. Short term Intervention 2: Nurse will offer strategies that will help minimize problems with colostomy during intercourse. Short term Intervention 3: Nurse will clarify any misconceptions about sexual difficulties. Long term Intervention 1: Nurse will encourage patient to discuss concerns with his partner. Long term Intervention 2: Nurse Short term Intervention 1 rationale 1: Open, honest discussions, expressing that changes will occur but that they are manageable promote feelings of control [Lin04] Short term Intervention 1 rationale 2: Discussions enable clarification about misconceptions [Pam04] Short term Intervention 2 Rationale 1: Assisting a patient with resuming previous lifestyle with minimal disruption is an Short Term: Patient stated two strategies that will help eliminate problems during intercourse. Long Term: Patient verbalizes his altered body structure does not affect his sexual activity any longer because of different strategies used.