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Nursing plan of care or intervention

Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the individual through the collection of both subjective and objective data. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan.
• To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness.
• To reflect on the interactive process between self and client when conducting a health assessment.

Explain expected client behaviors while differentiating between normal findings variations, and abnormalities. (PO 1)
Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (POs 4 & 8)
Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
Utilize effective communication when performing a health assessment. (PO 3)

Sample Answer

Understanding Subjective Data:

Physiological: This includes symptoms, pain levels, sleep patterns, appetite, fatigue, and any bodily discomfort. Normal: Age-appropriate energy levels, healthy sleep patterns, absence of pain or discomfort. Variations: Individual differences in sleep or energy needs, occasional aches or pains. Abnormalities: Persistent pain, significant changes in sleep or appetite, unusual bodily sensations.
Psychosocial: This covers emotions, stress levels, relationships, coping mechanisms, and social support. Normal: Age-appropriate emotional expression, healthy coping mechanisms, strong social support. Variations: Individual differences in emotional expression, use of healthy coping mechanisms, varied levels of social support. Abnormalities: Excessive anxiety or depression, unhealthy coping mechanisms (substance abuse, isolation), lack of social support.

Full Answer Section

Cultural/Spiritual: This explores cultural beliefs, practices, and spiritual values affecting health and well-being. Normal: Culturally appropriate health practices, expression of spiritual beliefs aligned with cultural norms. Variations: Individual variations within cultural or spiritual practices. Abnormalities: Practices contradicting medical advice due to cultural beliefs, spiritual distress.
Developmental: This considers age-appropriate behaviors, cognitive function, and developmental milestones. Normal: Age-appropriate behaviors, clear communication, meeting developmental milestones. Variations: Individual differences in development, slight delays in milestones. Abnormalities: Significant delays in development, communication difficulties, inappropriate behavior for age.

2. Integrating Subjective Data into Course Outcomes:

CO 1: Use your knowledge of expected behaviors for each category (physiological, psychosocial, etc.) to differentiate between normal, variations, and abnormalities in the collected data.
CO 2: Apply your understanding of relevant nursing theories and principles to interpret the subjective data and make clinical judgments about potential underlying issues.
CO 3: Consider how the client’s developmental stage might influence their responses and interpretation of their health concerns.
CO 4: Utilize active listening, open-ended questions, and cultural sensitivity while collecting the data to build rapport and encourage accurate information sharing.

3. Additional Resources:

Review your course materials on normal findings, cultural considerations, and communication techniques.
Explore online resources like the National Center for Complementary and Integrative Health for culturally specific health practices.
Practice active listening and open-ended questioning skills with a friend or family member.

Remember, while I can provide information and guidance, it’s crucial to consult your instructor or qualified healthcare professionals for specific advice and feedback on your assessment skills and course requirements.

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Nursing plan of care or intervention

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