Care Plan by Sections

Demographic Data & History o All sections are relevant to identifying potential patient problems and therefore must be complete. o Information can be extracted by direct interaction with the patient (patient assessment) and can be found within the patient chart.o

Student full name, date of clinical experience (not the date student completed or submitted the care plan), and admission date. Also document the careplan # (i.e.: Joan Smith: January 2, 2007 Care Plan #2: adm. date Dec 31, 2006). Patient initials only. Patient age for pediatric patient ( safety needs > psycho-social needs

o Actual problems usually precede risk or potential problems Nursing Diagnosis (statement, goals, interventions, rationales, evaluation)o

REMINDER: Nursing diagnosis are based on the specific assessment performed for assigned patient during the current visit.

o Use top 3 prioritized nursing diagnosis from previous section (unless otherwise stated by clinical instructor).o

Statement 3 parts

1st part - Problem statement identified from nursing assessment.5

2nd part - Related to (r/t) is the cause of the problem or contributing factors. 3rd part - As evidenced by (aeb) the subjective and objective signs/symptoms (s/s)/behavior/patient statements identified in the nursing assessment which support the problem. Use approved NANDA nursing diagnosis Must include an actual nursing diagnosis. May include a risk nursing diagnosis.

Risk diagnosis do not have evidence of the problem yet, so there will only be 2 parts to the risk nursing diagnosis statement (potential problem related to cause/or presence of risk factors0). An instructor may request students identify what evidence there would be if the diagnosis were an actual diagnosis. Write the s/s in parenthesis in a separate sentence. i.e.: Risk for infection related to inadequate primary defenses. (The evidence of infection would be fever, chills, muscle aches, increased WBC count).

An instructor may request students develop nursing diagnosis in various domains, such as physiologic, psychological, health promotion or education related. i.e.: Acute pain (problem) related to tissue ischemia, cardiac (cause of the problem) as evidenced by patient states chest pain is 8/10 (s/s of the problem).

o

Outcome criteria stated as expected goals. State at least one short term goal (immediate outcome) and one long term goal (may or may not be observed during your time with patient) for each diagnosis.. Must include all components: realistic patient action/behavior, time limited, specific, measurable i.e.: short term goal #1. Patient will have increased comfort and decreased pain level (0-3/10) within 2 hours of implementing comfort measures.

o

Interventions what is the nurse going to do to assist the patient to meet the established goal? Use action words such as assess, monitor, offer, discuss.6

List all relevant nursing interventions for each diagnosis. A minimum of 3 are required, yet students are encouraged to write more then 3. Interventions can be nursing prescribed or physician prescribed. Students should attempt to utilize primarily nursing prescribed interventions. There may be times when physician prescribed interventions are essential to be included as well. i.e.: impaired cardiac output related to altered heart rate and rhythm A critical intervention will include administration of prescribed beta-blockers (physician prescribed intervention) Interventions can be individual (initiated be the nurse independently) or collaborative (initiated in conjunction with other disciplines).

o

Rationales scientific explanation of why a specific intervention will work. Citations from credible source must be used for each rationale, when applicable.

o

Evaluation state whether or not the goal was fully met, partially met or not met and explain briefly. Compare findings with outcome criteria previously established. If there are interventions that did not work that should be noted so the plan can be altered. All short term goals must be valuated. It is expected that long term goals may not be met due to limited clinical experience.

References o Must be formatted in most current APA format style. OB specifics The primary difference in the OB care plans are the assessments and history. These will be reviewed by your instructor prior to clinical. Psychiatric specifics The differences in the Psychiatric care plans will be reviewed by your instructor prior to clinical. Attachments #2 General Care/Med-Surg care plan document #3 Nursery care plan document #3a OB care plan document #4 Psych care plan document

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Attachment #2: Med-Surg Care Plan Document

RN PROGRAM CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN STUDENT NAME: PATIENT INITIALS: AGE: PAIN:(Is client experiencing any pain?)

DATE: ALLERGIES:

LMP:

(mark n/a if not applicable)

HEIGHT: WEIGHT: Body Mass Index: HEAD CIRC: CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS GRAVIDA: PERCENTILE: PARA: AB:

PAST MEDICAL HISTORY

CURRENT ORDERS DIET: ACTIVITY: TREATMENTS: DEVELOPMENTAL ASSESSMENT PIAGETS STAGE: EVIDENCE: ERIKSONS STAGE: EVIDENCE:

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PHYSICAL ASSESSMENT(Complete head to toe assessment. WNL is not accepted. Please be specific.)

Neurologic:

Respiratory:

Cardiovascula r:

Gastrointestin al:

Genitourinary:

Musculoskelet al:

Integumentar y:

Psychosocial:

Nutritional:

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MEDICATIONS Please include trade & generic name, dosage, action, reason your patient is receiving this medication, major side effects, and nursing implications.Trade Name Drug Action Is Dose Appropriate ? Adverse Reactions Nursing Implications

Generic Name

PTs Weight

Dose

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions Nursing Implications

Generic Name PTs Weight Dose Route Trade Name Drug Action Is Dose Appropriate ? Adverse Reactions Nursing Implications

Generic Name PTs Weight Dose10

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

, fever

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose11

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose12

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

Route

LAB DATA & DIAGNOSTIC EVALUATIONInclude date

LAB Ordered

Client Values .

Normal Values

Indication for Diseases / Illness

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LAB Ordered

Client Values

Normal Values

Indication for Diseases / Illness

MEDICAL DIAGNOSIS MEDICAL DIAGNOSIS TEXTBOOK CLINICAL PICTUREDefinition, Signs, and Symptoms that should be seen

CLIENTS ACTUAL CLINICAL PICTUREWhat Signs and Symptoms your patient actually exhibited

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PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSISList all nursing diagnosis relevant to patient condition & based on assessment

1.

2.

3.

15

4.

5.

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Student Name: ____________ Patient Initials: _______________

Date: ____________________

NURSING CARE PLAN

Class: ______

A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include related to, as evidenced by, or risk factors (if at risk diagnosis) for each medical diagnosis. Write at least one/ expected outcome measurable goal per nursing diagnosis stated in terms of client achievement - the client will). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal.NURSING DIAGNOSIS(NANDA APPROVED)

EXPECTED OUTCOME (Measurable Goal)

NURSING INTERVENTIONS (What do you plan to do?)

RATIONALE (Why are you doing this?)

EVALUATION

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18

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

19

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

20

References(APA format)

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Attachment #3 Nursery Care Plan Document

RN PROGRAM CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN Nursery STUDENT NAME: Demographics: Patient initials: Maternal and labor history: LMP: Labor onset date, time: ROM date, time: Delivery date, time: Maternal health history: Labor complications: Maternal medication: Current Orders: Diet: Treatments: Other: Newborn assessment: Birth date, time: Weight birth: Length: Mom blood type: Delivery type: Weight today: Head circ: Baby blood type: Apgar: %age +/-: Chest circ: GBS status: Color: type: EDC: Age: Religion: Clinical Date:

Newborn physical exam (head to toe): 22 TCD/10-07

Patient observation Vital signs Temp HR R Skin Head Eyes, ears, nose Mouth Neck, chest (include cardiac and respiratory here) Abdomen Genitalia Male Female Back Extremities Neuro Reflexes

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Attachment #3a OB Care Plan

STUDENT NAME: Clinical Date: Demographics: Patient initials: History: Chief Concern: Past medical/surgical history: Current medical history: Obstetric history: G: Year T: P: A: Weeks gestatio n Sex L: Living c patient? Age: Religion: Allergies:

Delivery type (NSVD, LFD, vacuum, CS, SAB, TAB)

Labor history: LMP: Labor onset date, time: ROM date, time: Delivery date, time: Pain scale: Color: type: Pain control method: EDC:

Electronic Fetal Monitoring: FHR Variability Accelerations Decelerations

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Contractions

Frequency

Duration

Intensity

Current Orders: Diet: Activity: Treatments: Postpartum assessment: Patient observation

B

Breasts

U

Uterus

B

Bladder

B

Bowel

L

Lochia

E

Episiotomy/incision

H

Homans

E

Emotion

25 TCD/10-07

Attachment #4 Psych Care Plan Document

RN PROGRAM PSYCHIATRIC NURSING CLINICAL CARE PLAN Student Name: Patient Initials: Age: Height: Weight: PYSCHIATRIC DIAGNOSIS (Include DSM-IV-TR and definition): Axis I Axis II Axis III Axis IX Axis X PAST MEDICAL HISTORY: FAMILY HISTORY: STAGE OF DEVELOPMENT (Include developmental theorist and behaviors indicative of achievement of developmental tasks): Theorist: Evidence: SPIRITUAL BELIEFS: CULTURAL BELIEFS: Clinical Date: Clinical Site:

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ASSESSMENT(Please be specific)

General Assessment and Motor Behavior: (Hygiene and Grooming; Appropriate Dress;Posture; Eye Contact; Unusual Movements or Mannerisms; Speech)

Mood and Affect: (Expressed Emotions; Facial Expressions)

Thought Process and Content: (Content: what the client is thinking; Process: how the client isthinking; Clarity of Ideas; Self-harm or Suicidal Urges)

Sensorium and Intellectual Processes: (Orientation; Confusion; Memory; Abnormal SensoryExperiences or Misperceptions; Concentration; Abstract Thinking Abilities)

Judgment and Insight: (Judgment: interpretation of the environment; Decision-making Ability;Insight: understanding ones own part in his/her current situation)

Self-Concept: (Personal View of Self; Description of Physical Self; Personal Qualities orAttributes)

Roles and Relationships: (Current roles; Satisfaction with Roles; Success at Roles; SignificantRelationships; Support Systems)

Physiologic and Self-Care Issues: (Eating Habits; Sleep Patterns; Health Problems;Compliance with Medications; Ability to Perform ADLs)

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MEDICATIONS Please include trade & generic name, dosage, action, reason your patient is receiving this medication, major side effects, and nursing implications.Trade Name Drug Action Is Dose Appropriate ? Adverse Reactions Nursing Implications

Generic Name

). PTs Weight

Dose

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions Nursing Implications

Generic Name PTs Weight Dose Route Trade Name Drug Action Is Dose Appropriate ? Adverse Reactions Nursing Implications

Generic Name PTs Weight 28 TCD/10-07

Dose

Route

LAB DATA & DIAGNOSTIC EVALUATIONInclude date

LAB Ordered

Client Values .

Normal Values

Indication for Diseases / Illness

LAB Ordered

Client Values

Normal Values

Indication for Diseases / Illness

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PSYCHIATRIC MANAGEMENT PSYCHIATRIC DIAGNOSIS Define PRIMARY SECONDARY

Etiology

Pathophysiology

Clinical Manifestations (textbook)

Clinical Manifestations (actual)

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSISList all nursing diagnosis relevant to patient condition & based on assessment

1.

2.

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3.

4.

5.

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NURSING CARE PLANStudent Name: ____________ Patient Initials: _______________ A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include related to, as evidenced by, or risk factors (if at risk diagnosis) for each medical diagnosis. Write at least one/ expected outcome measurable goal per nursing diagnosis stated in terms of client achievement - the client will). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal.NURSING DIAGNOSIS(NANDA APPROVED)

Date: ____________________

Class: ______

EXPECTED OUTCOME (Measurable Goal)

NURSING INTERVENTIONS (What do you plan to do?)

RATIONALE (Why are you doing this?)

EVALUATION

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NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

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TCD/10-07

References(APA format)

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