NURSING CARE PLAN GUIDE
ASSESSMENT OF UNIVERSAL SELF CARE REQUISITES
DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient.
ASSESSMENT PLANNING EVALUATION
Universal Self Care Requisites Nursing Diagnosis Expected Outcomes Nursing Interventions Rationale Outcome Assessment
DEFINTION:
(USCR) the category of self-care
requites that are basic and common
to all humans and are constantly
present; these needs must be met to
achieve optimal health and well-
being. There are eight universal
self-care requisites:
(1) AIR
(2) FOOD
(3) WATER
(4) ELIMINATION
(5) ACTIVITY AND REST
(6) SOLITUDE AND
SOCIAL INTERACTION
(7) PREVENTION OF
HAZARDS
(8) NORMALCY
Self-Care Agency (SCA) - assets or
abilities of an individual to perform
self-care.
Self-Care Deficit (SCD) - deficit
relationship that exists when the
demand for self-care exceeds the
person's ability to perform self-care.
Nursing System: the series of
organized concrete action performed
by nurses in collaboration with the
patient. There are three types of
nursing systems:
(1) wholly compensatory
(2) partly compensatory
(3) supportive-educative
DEFINITION:
Problem: statement of the patient's
risk for or actual health problem that
the nurse is licensed and accountable
to treat.
Etiology: factors "related to" or
"associated with" the patient's
problem.
Signs and Symptoms:
manifestations of problem identified.
DEFINITION:
Desired or expected outcomes or
resolution of nursing diagnosis.
"Patient will" __________________
_____________________________
_____________________________
or
to ___________________________
_____________________________
_____________________________
DEFINITION:
Direction for nursing action
designed to assist the client and/or
significant other to meet the
expected outcomes. Nursing actions
are specific, realistic, and
individualized for a particular
patient.
Components of nursing actions:
1. Precision action verb
2. Content area
a. What-the actual measure
performed
b. Where - specific area
c. How- the means by which
measures will be adopted
d. When - time element, how
long or how often the
nursing action is to occur
3. Categories of Interventions
A - assessment
C - care & comfort measures
T - teaching
Independent, dependent,
collaborative, and supportive -
educative nursing actions are to be
considered when writing the plan
DEFINTION:
Scientific principles, theories or
concepts underlying nursing
interventions:
Document all reference sources with
author, title edition and page.
DEFINTION:
Responses to or results of nursing
interventions. An assessment of
relative data is made. These
outcome assessments describe how
the patient looks, feels or behaves
after nursing action has been
implemented.
May include proposed modifications
or present plan for improvement of
nursing care.
(Rev. 5/04)
