Nursing care plan on nursing theories

Florence Nightingale, often considered the founder of modern nursing, contributed

significantly to nursing theory and practice. Her environmental theory emphasized the impact of the
environment on patient health and recovery. Here's a simplified nursing care plan based on Nightingale's
principles:

Nursing Diagnosis:

Impaired Comfort related to environmental factors as evidenced by patient's complaints of discomfort

and restlessness.

Goals:

1. Patient Comfort: Ensure the patient experiences comfort and relaxation.

2. Environment: Maintain a clean, quiet, and well-ventilated environment conducive to healing.

Nursing Interventions:

1. Assess Environmental Factors:

o Monitor lighting, noise levels, temperature, and cleanliness of the patient's

environment.

o Ensure the room is well-ventilated and free of unpleasant odors.

2. Promote Comfort:

o Provide pain relief interventions as necessary (e.g., medications as ordered).

o Assist with positioning to enhance comfort and prevent pressure ulcers.

3. Promote Hygiene:

o Assist with personal hygiene as needed (e.g., bathing, changing linens).

o Ensure the patient's clothing and bedding are clean and dry.

4. Monitor Fluid and Nutrition:

o Encourage adequate fluid intake unless contraindicated.

o Monitor nutritional intake and consult with dietitian as needed.

5. Educate Patient and Family:

o Educate on the importance of a supportive environment in promoting healing.

o Instruct on measures to maintain cleanliness and comfort in the patient's surroundings.

 6. Evaluate and Document:

o Regularly assess the patient's comfort level and document findings.

o Record environmental factors and their impact on the patient's well-being.

Evaluation:

 Patient reports decreased discomfort and improved rest.

 Environment remains conducive to healing based on assessments.

Dorothea Orem's Self-Care Deficit Nursing Theory emphasizes the patient’s ability to perform
self-care and the nurse’s role in assisting when there is a deficit in this ability. The goal is to help the
patient achieve the highest level of self-care possible.

Nursing Diagnosis:

Self-Care Deficit related to limited physical mobility as evidenced by the patient's inability to perform
activities of daily living (ADLs) independently.

Goals:

1. Short-term Goal: Patient will demonstrate partial independence in performing ADLs within one
week.

2. Long-term Goal: Patient will achieve maximum possible independence in self-care activities
within one month.

Nursing Interventions:

1. Assessment of Self-Care Abilities:

o Evaluate the patient’s current ability to perform ADLs (e.g., bathing, dressing, feeding,
toileting).

o Assess the patient’s physical, cognitive, and emotional status to identify barriers to self-
care.

2. Encourage Participation in Self-Care:

o Encourage the patient to perform tasks independently as much as possible, offering

assistance only when needed.

o Use adaptive devices or modify the environment to facilitate self-care (e.g., using grab
bars, special utensils).

3. Education and Skill Development:

o Teach the patient techniques to improve self-care (e.g., energy conservation methods,
proper body mechanics).
 o Educate the patient and family about the importance of maintaining independence in
self-care activities.

4. Support and Motivation:

o Provide positive reinforcement and encouragement to build the patient’s confidence in

performing self-care tasks.

o Involve the patient in setting realistic goals for improvement in self-care abilities.

5. Collaborate with Other Healthcare Providers:

o Work with physical therapists, occupational therapists, and other healthcare

professionals to develop a comprehensive care plan.

o Ensure coordination of care to address all aspects of the patient’s self-care deficit.

6. Monitor and Evaluate Progress:

o Regularly assess the patient’s progress in self-care activities.

o Adjust the care plan as needed based on the patient’s improvement or any new
challenges that arise.

Evaluation:

 Short-term: Patient demonstrates improved ability in performing some ADLs with minimal
assistance.

 Long-term: Patient achieves maximum possible independence in self-care, with reduced

assistance required from the nursing staff.

This care plan, based on Orem's theory, focuses on enhancing the patient's self-care capabilities,
supporting them in achieving greater independence, and ensuring that care is tailored to their individual
needs and abilities.

Virginia Henderson’s Nursing Need Theory emphasizes the nurse's role in assisting patients
with activities that contribute to health, recovery, or a peaceful death, which they would perform
unaided if they had the strength, will, or knowledge. Henderson identified 14 basic needs of individuals
that form the foundation of nursing care.

Nursing Diagnosis:

Impaired Physical Mobility related to postoperative pain and weakness as evidenced by the patient’s
inability to ambulate independently.

Goals:

1. Short-term Goal: Patient will verbalize a reduction in pain and demonstrate slight improvement
in mobility with assistance within 3 days.
 2. Long-term Goal: Patient will achieve independent ambulation or minimal assistance in mobility
within 2 weeks.

Nursing Interventions:

1. Assess Patient’s Basic Needs:

o Assess the patient's ability to perform the 14 basic needs, including breathing, eating,
elimination, movement, sleep, and safety.

o Identify which needs are unmet due to impaired mobility and pain.

2. Pain Management:

o Administer pain medication as prescribed, and monitor the effectiveness of pain relief
interventions.

o Use non-pharmacological methods for pain relief, such as positioning, heat/cold therapy,
and relaxation techniques.

3. Promote Mobility:

o Assist the patient with gradual mobilization, starting with passive range-of-motion
exercises and progressing to sitting, standing, and walking with assistance.

o Use assistive devices like walkers or canes to aid in mobility and prevent falls.

4. Support Nutrition and Hydration:

o Encourage and assist the patient with eating a balanced diet and adequate fluid intake to
support recovery.

o Monitor nutritional intake and collaborate with a dietitian if necessary.

5. Ensure Safety and Comfort:

o Keep the patient’s environment safe by removing obstacles and ensuring proper lighting.

o Provide comfortable positioning and bedding to prevent pressure ulcers and discomfort.

6. Educate Patient and Family:

o Teach the patient and family members about the importance of mobility in recovery,
pain management strategies, and safe use of assistive devices.

o Provide information on exercises and activities that can be continued at home to

maintain mobility and independence.

7. Evaluate and Document:

o Regularly assess the patient's progress in mobility, pain levels, and ability to meet basic
needs independently.

o Document any changes in the patient's condition and adjust the care plan accordingly.
Evaluation:

 Short-term: Patient reports decreased pain and shows slight improvement in mobility with
assistance.

 Long-term: Patient achieves independent ambulation or requires minimal assistance, with most
basic needs being met independently.

This care plan, grounded in Henderson's theory, focuses on helping the patient achieve greater
independence by meeting their basic needs, especially in relation to mobility and pain management,
while supporting their overall well-being.

Jean Watson's nursing theory, often referred to as the Theory of Human Caring or the Watson
Caring Science Institute, emphasizes the importance of humanistic aspects in nursing care. Creating a
nursing care plan based on Watson's theory involves integrating principles of caring, compassion, and
holistic patient care. Here’s a simplified outline for a nursing care plan inspired by Jean Watson's
theories:

Nursing Diagnosis:

 Impaired Comfort related to [specific patient condition]

o Evidence: [Describe patient's manifestations of discomfort or pain]

Goals:

 Short-term Goal:

o Patient will report a decrease in pain intensity from [current level] to [desired level]
within 24 hours.

 Long-term Goal:

o Patient will demonstrate improved comfort and well-being as evidenced by [specific

behaviors, such as improved sleep patterns or relaxed facial expressions] within one
week.

Interventions:

1. Establish a Therapeutic Relationship:

o Implement Watson’s caring model to create a trusting and supportive nurse-patient

relationship.

o Use active listening and therapeutic communication techniques to understand patient

needs and concerns.

2. Promote Comfort and Emotional Support:

o Provide pain management interventions as ordered (e.g., medications, positioning).

 o Offer therapeutic touch and comforting gestures to promote relaxation.

3. Enhance Patient's Sense of Security and Trust:

o Ensure a calm and comforting environment conducive to healing.

o Respect patient preferences and promote autonomy in decision-making related to care.

4. Facilitate Spiritual and Emotional Well-being:

o Assess and address spiritual needs through supportive conversation or referral to a

chaplain or spiritual counselor.

o Encourage patient expression of feelings and concerns to foster emotional healing.

5. Educate and Empower Patient and Family:

o Provide education on the patient's condition, treatment options, and self-care strategies.

o Encourage family involvement and support in the patient's care plan.

Evaluation:

 Short-term Evaluation:

o Assess patient's pain level and comfort status 24 hours after initiating interventions.

o Evaluate patient-reported outcomes and adjust interventions as needed.

 Long-term Evaluation:

o Review patient progress toward achieving long-term goals (e.g., improved comfort,
enhanced emotional well-being).

o Modify care plan as necessary to promote continued healing and recovery.

This care plan incorporates Jean Watson's emphasis on caring and holistic patient care, aiming to
promote comfort, emotional support, and overall well-being through a therapeutic nursing approach.

Sister Callista Roy's Adaptation Model focuses on how individuals adapt to changes in their
environment. The model views the patient as a bio-psycho-social being who is constantly interacting
with internal and external stimuli. Nursing interventions are aimed at helping the patient adapt positively
to changes.

Here’s a simplified nursing care plan based on Callista Roy’s Adaptation Model:

Nursing Diagnosis:

 Ineffective Coping related to [specific stressor or health condition]

o Evidence: [Describe the patient's signs of ineffective coping, such as anxiety, confusion,
or withdrawal]

Goals:
  Short-term Goal:

o Patient will identify at least two effective coping strategies within 48 hours.

 Long-term Goal:

o Patient will demonstrate effective adaptation to stressor(s) as evidenced by [specific

behaviors, such as improved mood, engagement in activities, or self-care practices]
within one week.

Interventions:

1. Assessment of Adaptive Modes:

o Physiological Mode: Assess the patient's physical health, including vital signs, pain
levels, and physical functioning.

o Self-Concept Mode: Evaluate the patient’s self-esteem, body image, and emotional well-
being.

o Role Function Mode: Determine how the patient's role in family, work, or society is
being affected by the current situation.

o Interdependence Mode: Assess the patient’s social relationships and support systems.

2. Promote Physiological Adaptation:

o Provide interventions to manage symptoms, such as pain relief, nutritional support, and
hydration.

o Monitor and support physical recovery processes, ensuring the patient’s environment
supports healing (e.g., maintaining cleanliness, temperature control).

3. Support Self-Concept and Emotional Adaptation:

o Use therapeutic communication to help the patient express emotions and concerns.

o Reinforce positive aspects of the patient’s identity and self-worth, encouraging self-
compassion and resilience.

o Provide resources such as counseling or support groups if needed.

4. Facilitate Role Function Adaptation:

o Help the patient understand any changes in their role (e.g., family dynamics, work
responsibilities) due to their health condition.

o Encourage the patient to engage in meaningful activities that align with their current
abilities, fostering a sense of purpose and normalcy.

5. Enhance Interdependence and Social Support:

 o Identify and strengthen the patient’s support systems, including family, friends, and
community resources.

o Encourage open communication between the patient and their loved ones to foster
mutual support and understanding.

o Facilitate connections with social or spiritual groups that can offer additional support.

Evaluation:

 Short-term Evaluation:

o Reassess the patient’s coping mechanisms and emotional status after 48 hours.
Determine if the patient has identified and started using effective coping strategies.

o Adjust interventions as needed to address any ongoing difficulties in coping.

 Long-term Evaluation:

o Evaluate the patient’s overall adaptation to the stressor(s) after one week. Look for signs
of effective adaptation, such as improved emotional well-being, restored role function,
and strengthened support systems.

o Modify the care plan to continue supporting the patient’s adaptation as their situation
evolves.

This care plan integrates Callista Roy's focus on helping patients adapt in various aspects of their lives,
emphasizing the importance of supporting physiological, emotional, role function, and interdependence
adaptation.

Patricia Benner's nursing theory, known as "From Novice to Expert," focuses on the
development of nursing skills through clinical experience. Benner describes five levels of nursing
proficiency: novice, advanced beginner, competent, proficient, and expert. The theory emphasizes that
clinical knowledge is developed over time through a combination of experience and education.

Here's a nursing care plan based on Benner's theory:

Patient Information:

 Patient Name:

 Age:

 Gender:

 Medical Diagnosis:

 Date:
Nursing Diagnosis:

 Knowledge Deficit related to new diagnosis of [Insert Diagnosis] as evidenced by patient’s

verbalization of concerns about treatment plan and lack of understanding of the condition.

Goals:

1. The patient will demonstrate understanding of their diagnosis and treatment plan within 24
hours.

2. The patient will correctly perform any required self-care tasks (e.g., medication administration,
wound care) by the end of the hospital stay.

3. The patient will express increased confidence in managing their condition before discharge.

Interventions:

1. Assessment of Patient's Knowledge Level:

o Assess the patient’s current understanding of their condition, treatment plan, and any
self-care responsibilities.

o Determine the patient’s learning style (visual, auditory, kinesthetic) to tailor education.

2. Education and Teaching:

o Provide individualized education about the diagnosis, treatment options, and expected
outcomes.

o Use appropriate educational materials (e.g., pamphlets, videos, models) that align with
the patient’s learning style.

o Break down complex medical terms and concepts into simple, understandable language.

3. Skill Development:

o Demonstrate any required self-care tasks (e.g., blood glucose monitoring, insulin
administration) and then have the patient practice under supervision.

o Provide step-by-step written instructions to reinforce verbal teaching.

4. Encouragement and Support:

o Encourage the patient to ask questions and express any concerns or fears.

o Provide positive reinforcement and feedback as the patient gains competence in

managing their condition.

5. Evaluation of Learning:
 o Assess the patient’s understanding of the information provided through teach-back
methods (e.g., asking the patient to explain concepts in their own words).

o Reassess and provide additional education or clarification as needed.

Expected Outcomes:

1. The patient will be able to accurately describe their condition and the rationale for their
treatment plan.

2. The patient will perform self-care tasks independently and correctly.

3. The patient will report feeling confident in managing their condition by the time of discharge.

Rationale:

 Benner’s theory suggests that nursing care should be tailored to the patient's level of
understanding and experience. By assessing the patient’s current knowledge and providing
appropriate education and support, the nurse can facilitate the patient's progression from
novice to a more competent level of self-care.

Evaluation:

 Review the patient’s progress regularly, adjusting the care plan as needed based on the patient’s
demonstrated knowledge and competence.

This care plan integrates the principles of Patricia Benner’s theory by focusing on the patient’s learning
and skill development, gradually building their confidence and competence in managing their health
condition.

Patricia Benner is renowned for her Novice to Expert theory. She emphasized that nursing
skills and understanding develop over time through experience. Benner's model suggests that nurses
move through five levels of proficiency: Novice, Advanced Beginner, Competent, Proficient, and Expert.

Here's a basic nursing care plan incorporating Benner's theory:

Nursing Care Plan: Applying Patricia Benner's Novice to Expert Theory

Patient Name: [Patient's Name]

Date: [Date]
Nurse's Name: [Nurse's Name]
Diagnosis: [Patient's Diagnosis]

Assessment:

 Patient's Current Condition: (Include vital signs, symptoms, medical history, etc.)
  Patient's Level of Understanding and Experience with Their Health Condition: (Assess where
the patient stands in understanding their health status and what they've learned so far.)

Nursing Diagnosis:

 Knowledge deficit related to the new diagnosis, lack of experience, or unfamiliarity with
managing the condition.

 Anxiety related to the new or worsening health condition, lack of knowledge, and lack of
experience in managing the health issue.

Goals/Outcomes:

1. Short-term Goal: The patient will demonstrate understanding of their condition and the
necessary self-care practices within 48 hours.

2. Long-term Goal: The patient will independently manage their condition using the newly
acquired knowledge and skills within one month.

Nursing Interventions:

1. Assess the Patient's Current Knowledge and Experience:

o Identify the patient's level of understanding of their condition and care (e.g., Novice,
Advanced Beginner, etc.).

o Adjust teaching methods based on the patient's current level of experience and
knowledge.

2. Educate the Patient Using Incremental Learning:

o Start with simple, clear instructions tailored to the patient's level.

o Use practical examples and hands-on demonstrations to enhance understanding.

3. Encourage Participation and Practice:

o Allow the patient to participate in their care to build confidence and skills.

o Supervise and provide constructive feedback as the patient practices self-care activities.

4. Monitor and Reassess:

o Regularly evaluate the patient's progress and understanding.

o Adjust the teaching plan according to the patient’s growth in understanding and
proficiency.

5. Provide Emotional Support:

o Offer reassurance and address any anxieties or concerns the patient may have.

o Encourage questions and provide clear, empathetic responses.

Evaluation:

 Short-term Goal: Evaluate the patient's ability to recall information and demonstrate basic self-
care skills within the set timeframe.

 Long-term Goal: Assess the patient’s ability to manage their condition independently, with
minimal guidance, over time.

Signature of Nurse: __________________

Date: __________________

1. Hildegard Peplau's Interpersonal Relations Theory

This theory emphasizes the nurse-patient relationship as the core of nursing care, focusing on the
interaction between nurse and patient to support healing.

Nursing Care Plan:

Patient: John, 45 years old, admitted for depression.

Nursing Diagnosis: Anxiety related to unresolved interpersonal conflicts.
Goal: Establish a therapeutic relationship to help the patient understand and resolve anxiety.

Nursing Diagnosis Goals/Outcomes Nursing Interventions Evaluation

1. Establish trust by active

listening and empathy
during conversations.
Patient will express feelings Patient feels more
Anxiety related to 2. Engage patient in
and concerns regarding comfortable sharing
interpersonal regular sessions to discuss
personal relationships within 3 feelings and reports
conflicts feelings.
days reduced anxiety.
3. Encourage open
communication and
reflection.

1. Assist patient in
identifying meaningful
social relationships. Patient reports improved
Altered social Patient will identify at least
2. Encourage the patient social interactions and
interaction due to one positive social interaction
to interact with family or reduced feelings of
depression per day within a week.
friends. loneliness.
3. Provide feedback and
reassurance.

2. Betty Neuman's Systems Model

This model views the patient as a system affected by stressors in multiple environments. Nursing
interventions aim to maintain system stability.

Nursing Care Plan:

Patient: Sarah, 30 years old, post-operative patient experiencing high levels of stress.
Nursing Diagnosis: Risk for infection related to surgical incision stressor.

Nursing Diagnosis Goals/Outcomes Nursing Interventions Evaluation

1. Monitor vital signs,

especially for signs of
infection.
2. Implement strict hand Patient’s surgical wound
Risk for infection Patient will remain free
hygiene and aseptic shows no signs of infection,
related to surgical from infection during the
techniques. and patient reports feeling
stress hospital stay.
3. Provide emotional less stressed.
support to reduce stress-
related immune
suppression.

1. Teach relaxation
techniques to reduce
stress.
Ineffective coping Patient will verbalize 2. Provide emotional Patient reports using coping
related to effective coping strategies support through strategies and demonstrates
hospitalization stress within 3 days. counseling. reduced anxiety.
3. Collaborate with other
healthcare providers to
manage stressors.

3. Afaf Meleis's Transitions Theory

Meleis’s theory focuses on assisting patients through life transitions, such as changes in health status,
roles, or environments, by providing support and preparing them for those changes.

Nursing Care Plan:

Patient: Emily, 60 years old, recently diagnosed with diabetes.

Nursing Diagnosis: Knowledge deficit related to new diabetes diagnosis.

Nursing Diagnosis Goals/Outcomes Nursing Interventions Evaluation

Knowledge deficit Patient will demonstrate 1. Educate patient on the Patient demonstrates
related to diabetes understanding of diabetes pathophysiology of proper blood glucose
diagnosis management within 1 diabetes and its impact on monitoring techniques and
week. health. verbalizes understanding of
Nursing Diagnosis Goals/Outcomes Nursing Interventions Evaluation

2. Teach patient self-care

strategies, such as blood
sugar monitoring and
insulin administration.
the condition.
3. Provide emotional
support as the patient
adjusts to the new
diagnosis.

1. Encourage patient
participation in care
Patient will express decisions. Patient actively participates
Powerlessness
understanding of managing 2. Provide resources for in care decisions and
related to chronic
diabetes and feel diabetes support groups. reports feeling more in
illness transition
empowered within 1 week. 3. Acknowledge patient’s control of the condition.
concerns and provide
reassurance.

These care plans align with each theorist’s unique nursing perspective, addressing the holistic needs of
the patient through personalized care interventions.