Care Plan
Camden County College
Nursing Care Plan
Student: Date:9/16/2103
Pt. Data
Objective & Subjective
Nursing Diagnoses
Goals (Short & long term
Interventions & Rationale
Pt. Teaching
Eval.
Subjective Data
Patient states “I am afraid all the steroids are going to make me fat.” And was crying
Patient was asking questions about covering the butterfly rash.
Patient showed concern about swelled hand. She stated she did not want to look “crippled. “
Objective Data
Patient is a healthy weight. She is concerned about the weight gain from the steroids. She ate about 75% of her breakfast and lunch trays.
Slight butterfly rash on face
Swollen finger/hands
Slow gait
Weak body movements
Disturbed body image related to presence of rash, swelling, and weakness
Pt. will be able to: verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and will be able to verbalize understanding of body changes by 30 minutes
After 7 days, the patient will be able to recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem.
Intervention: Acknowledge and accept expression of feelings of frustration, grief, hostility. Note withdrawn behavior and use of denial
Rationale: Acceptance of this feeling as a normal response to what has occurred facilitates resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems
Intervention: Provide open environment for client to discuss concerns
Rationale: To promote sharing of beliefs/values about sensitive subject, and identifies misconceptions/myths that may interfere with adjustment to the situation
Intervention Encourage good nutrition, sleep habits, exercise, rest and relaxation techniques.
Rationale: To improve general health and help prevent infection.
Nursing Care Plan
Student: Date:9/16/2103
Pt. Data
Objective & Subjective
Nursing Diagnoses
Goals (Short & long term
Interventions & Rationale
Pt. Teaching
Eval.
Subjective Data
Patient states “I am afraid all the steroids are going to make me fat.” And was crying
Patient was asking questions about covering the butterfly rash.
Patient showed concern about swelled hand. She stated she did not want to look “crippled. “
Objective Data
Patient is a healthy weight. She is concerned about the weight gain from the steroids. She ate about 75% of her breakfast and lunch trays.
Slight butterfly rash on face
Swollen finger/hands
Slow gait
Weak body movements
Disturbed body image related to presence of rash, swelling, and weakness
Pt. will be able to: verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and will be able to verbalize understanding of body changes by 30 minutes
After 7 days, the patient will be able to recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem.
Intervention: Acknowledge and accept expression of feelings of frustration, grief, hostility. Note withdrawn behavior and use of denial
Rationale: Acceptance of this feeling as a normal response to what has occurred facilitates resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems
Intervention: Provide open environment for client to discuss concerns
Rationale: To promote sharing of beliefs/values about sensitive subject, and identifies misconceptions/myths that may interfere with adjustment to the situation
Intervention Encourage good nutrition, sleep habits, exercise, rest and relaxation techniques.
Rationale: To improve general health and help prevent infection.