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 (<3 yrs) it is essential to be exact: i.e.: 0-1 month use days, 30 days to 3 months use weeks, 21months, 2 years = 24 months, etc. Allergies include all identified food and drug allergies, including patient response. i.e.: amoxicillin causes hives or peanuts causes anaphylaxis Pain - indicate on 0-10 scale. Indicate scale used for non-verbal and pediatric patients. Growth Indicators: Height may be excluded for adults unless significant to medical or nursing diagnosis. Body Mass Index (BMI) and the interpretation (underweight, normal weight, overweight, obese, morbidly obese) should be included for adults. Height, weight, head circumference (less then ___ months) and percentile MUST be completed on all pediatric patients. Use most current growth charts (National Center for Health Statistics) available in textbook.

o o

o o

Chief complaint (CC) statement of what brought patient in for care. List signs and symptoms patient may have presented with. Usually stated in patient words. History of Present Illness (HPI) events or situation leading up to patient presenting for care. The HPI is the how, when where, what and why? of the chief complaint.
1

Past Medical History (PMH) List any chronic illness, past surgical procedures, previous hospitalizations or any other relevant information related to current health state. Current Orders include diet, activity allowed, treatment/therapies and consults. This information is usually obtained from either the kardex or directly from the initial physician orders. Examples include:

Diet - soft, regular, 1800cal, TPN Activity bed rest, up ad lib, OOB Q4hrs for 15 minutes, Turn Q 2hrs Treatments chest physiotherapy (CPT).

Developmental Assessment

Both Piaget and Erickson stage of development should be documented. The stage the patient should be in and the evidence that the patient either is or is not in that stage of development. Piaget focused on cognitive development therefore the evidence of that stage should be documented in terms of cognition. i.e.: patient statements, observations or information from patients history can be used to provide examples/evidence. Erickson focused on psychosocial development therefore the evidence should be documented in the sense of meeting expected social/emotional milestones and may be exemplified by the patients interaction with others or by their role in society.

Physical Assessment
o

If in an observation unit, note this at beginning of physical assessment and document inspection for each system. Identify what other parameters of the assessment may have been taken from the chart due to not being able to touch patient for assessment data. i.e.: Respirations unlabored, no accessory muscle use. FROM CHART: BBS equal and clear.

o Do not use the term normal or appropriate to describe a system or a parameter of a system. Norms must be explained. i.e.: INCORRECT gait is normal. CORRECT ambulates with steady gait, no limp, able to bear weight.
2

o Vital signs should be placed at the beginning of the physical assessment and may be incorporated into the appropriate system. i.e.: respiratory rate at beginning of respiratory assessment. o Consider order of assessment for each system and document as such. i.e.: inspect, percuss, palpate, auscultate for most systems. Inspect auscultate, percuss, palpate for GI system.

o Infusing IV fluids (type, rate, pump or straight drip set) should be included in CV section with site assessment in either this section or in the integumentary section. o IV access devices/sites (without infusing fluids) should be in the integumentary section. o TPN infusions should be in the GI section, with site assessment in integumentary.
o

Continuous monitoring device(s) (pulse oximeter, cardiac monitor, etc) should be included in the appropriate section (O2 sats in respiratory section, CM in CV section).

Medications o It is not appropriate to cut & paste all information received from a medication textbook/handbook.
o

Include ALL medications patient is currently taking (generic and trade name; dose; safe dose range; route; frequency; implications; side effects and special nursing implications). Pediatrics: document recommended dose range for weight and show calculation to determine safe/therapeutic/subtherapeutic/unsafe dose for the assigned patient. ALL medications includes scheduled, STAT, PRN and one time dose orders. There is no limit to how many drugs should be included in the care plan unless specified by the instructor. Implications this includes the rationale given in the drugbook which is usually listed as the implications for the medication. In addition the student is expected to note why the specific patient is receiving that specific medication. i.e.: Patient is receiving heparin sodium for anticoagulation (according to textbook). Patient is receiving the anticoagulant Heparin sodium for treatment of the deep vein thrombosis (according to student care plan).
3

Nursing implications: this section should include what is significant and relevant (specific assessment, lab data, antidotes, expected outcome, etc) to the nurse and should not be a repeat of the side effects. This section may include some of the interventions listed within the nursing care plan section. Students should ask themselves; what is special about this medication that would affect my patient. i.e.: if giving lasix a nursing consideration would be to monitor I&O, monitor electrolytes, assess for dehydration. If giving morphine IV a nursing consideration would be monitor respiratory rate/rhythm/quality, place patient on pulse oximeter and have narcan (reversal agent) readily available.

Lab Data & Diagnostic Evaluations o Include ALL relevant diagnostic tests/evaluation

i.e.: lab test (CBC, Chemistry, coagulation studies), radiographic studies such as magnetic resonance imaging (MRI), Computed tomography (CT), ultrasound, biopsy, electrocardiogram (ECG), etc.

o Include the expected normal values/findings. o Include patients values/findings and the date the diagnostic tests was done. o List or discuss the implications of the findings. If patients labs are within normal limits (WNL) but may have been expected to be abnormal, list what variations one would expect to find and critically think what intervention may have caused patient labs to result normal. i.e.: patient has bacterial meningitis, yet he is on hospital day 4 of antibiotic therapy and the most recent WBC is WNL, write that the WBC would be expected to have been elevated due to bacterial infection and antibiotics have helped to resolve the infection.

If the patient does not have recent labs/diagnostic tests, write what would be indicated for a patient with a similar diagnosis.

o Use citations (lab textbook), it is not necessary to cite the patients chart for patient lab value column. Medical Diagnosis o Using an approved source (course textbooks are sufficient, web-based program such as wikpedia is not) write the definition and presentation (signs/symptoms) identified with the patient medical diagnosis. o All definitions must be cited using APA format. If definition is taken verbatim from a source, it must be in quotes.
4

o There may be more then one medical diagnosis for each patient. Any relevant diagnosis that affects or are related to current medical status should be disclosed. o If the patient only has one medical diagnosis and no significant medical history, it is expected that there will be only one diagnosis defined. o If the patient does not have a confirmed medical diagnosis yet, identify what the differential diagnosis is/are or what the patient is being evaluated for and define it. i.e.: Patient is admitted for altered mental status, rule out sepsis and rule out transient ischemic attack (TIA). Neither diagnosis is confirmed to have caused the altered mental status. Write a medical diagnosis on both Sepsis and TIA. o List all signs/symptoms exhibited by the assigned patient (either observed or documented in patient chart). If the patient had no signs/symptoms state asymptomatic. Prioritized Nursing Diagnosis Statements
o

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

o Single statement nursing dx. i.e.: ineffective breathing pattern, knowledge deficit, anxiety, risk for injury. o List all relevant nursing diagnosis in prioritized order. High priority - if problem is not addressed/managed it will lead to patient deterioration. Low priority treatment can be delayed.

o Use Maslows hierarchy to assist with deciding whats most important. Physiologic needs > 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).

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.

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).

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

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

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:

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:

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 Dose

10

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 Dose

11

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 Dose

12

Route

Trade Name

Drug Action

Is Dose Appropriate ?

Adverse Reactions

Nursing Implications

Generic Name PTs Weight Dose

Route

LAB DATA & DIAGNOSTIC EVALUATION

Include date

LAB Ordered

Client Values .

Normal Values

Indication for Diseases / Illness

13

LAB Ordered

Client Values

Normal Values

Indication for Diseases / Illness

MEDICAL DIAGNOSIS MEDICAL DIAGNOSIS TEXTBOOK CLINICAL PICTURE

Definition, Signs, and Symptoms that should be seen

CLIENTS ACTUAL CLINICAL PICTURE

What Signs and Symptoms your patient actually exhibited

14

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

List all nursing diagnosis relevant to patient condition & based on assessment

1.

2.

3.

15

4.

5.

16

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

17

18

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

19

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

20

References
(APA format)

21 TCD/10-07

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

23 TCD/10-07

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

24 TCD/10-07

Contractions

Frequency

Duration

Intensity

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

Breasts

Uterus

Bladder

Bowel

Lochia

Episiotomy/incision

Homans

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:

26 TCD/10-07

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 is
thinking; Clarity of Ideas; Self-harm or Suicidal Urges)

Sensorium and Intellectual Processes: (Orientation; Confusion; Memory; Abnormal Sensory

Experiences 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 or

Attributes)

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

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

27 TCD/10-07

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 EVALUATION

Include date

LAB Ordered

Client Values .

Normal Values

Indication for Diseases / Illness

LAB Ordered

Client Values

Normal Values

Indication for Diseases / Illness

29 TCD/10-07

PSYCHIATRIC MANAGEMENT PSYCHIATRIC DIAGNOSIS Define PRIMARY SECONDARY

Etiology

Pathophysiology

Clinical Manifestations (textbook)

Clinical Manifestations (actual)

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

List all nursing diagnosis relevant to patient condition & based on assessment

1.

2.

30 TCD/10-07

3.

4.

5.

31 TCD/10-07

NURSING CARE PLAN

Student 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

32

TCD/10-07

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

EVALUATION

33

TCD/10-07

References
(APA format)

34 TCD/10-07