Start with where the patient is and go one to two steps higher:
Example: Patient is a 25 y/o female, non-smoker, non-drinker.
Has history of participation in sports in high school PE classes (bowling, archery, volley ball). Since being out of high school, works part-time and attends classses at a community college.
Most of her friends have moved away and she is reluctant to excerise on her own initiative.
Nursing diagnois: Activity intolerance/potential for growth
Nursing Intervention: Work with this patient to begin engaging in activities that she will realistically remain in, developing healthy patterns that will last her lifetime. Begin slowly, move slowly and add an additional activity only when the patient is ready(she may easily become overwhelmed if too much change is brought about too fast. Exsample: find a bowling leauge that meets monthly. This is a reasonable first step, can be participated in 12 months a year. During the warm months, she can participate in an out door volleyball group with folks from her school. Encourage her to take an archery class via her local park district or community college. Use a calendar to formally plan/schedule her activities (in ink, this increases her internalization of committment)
With many wellness promotion activities, the nurse just mearly has to sow the seeds on fertile ground, the patient will continue to grow and blossom.
To write really good care plans
: Visit C.V. Mosby and buy the following five (5) texts:
Nursing Diagnosis, 2002-2003, Current taxonomy, NANDA
Nursing Diagnosis, Gordon, Marjory, This is an excellent little handbook using Functional Health Patterns typology, an excellent framework for looking at the total person.
Nursing Interventions Classification, McCloskey, Joanne and Bulecheck.
Nursing Outcomes Classifications, Johnson, M. and Maas, Merideann
These volumes provide the most up-to-date languages for science- based nursing practice. Use them for all your care plans in all clinical areas and get an A on your care plans (note that your instructor may not even be familiar with these, he/she has the opprotunity to learn from the students)