LINCOLN MEMORIAL UNIVERSITY - Get Now DOC

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					                  LINCOLN MEMORIAL UNIVERSITY
                       Caylor School of Nursing
                         Nursing 124, 125, 241
          DAILY CARE PLAN & CONCEPT MAPPING GUIDELINES

    Daily Care Plans:
   1. Daily care plans/concept mapping must be completed on each assigned patient in
      order to receive a grade of satisfactory in the clinical area.

   2. Daily care plans/concept mapping are due on the second clinical day of each week
      unless the instructor states otherwise.

   3. There are three areas to be addressed on each daily care plan:
         a. Nursing Diagnosis
             (1). Write 2 nursing diagnoses in complete form, i.e., nursing
                   diagnosis related to….as evidenced by….. (There should be three (3)
                   parts.) These will be written on the concept map.

             (2). Fully develop the nursing diagnoses, i.e., include
                  assessment, short-term goals, interventions and evaluation.

             (3). State short-term goals for the nursing diagnoses that you fully
                  develop. These goals should be measurable and written in terms
                  of patient behavior, not nurse behavior.

          b. Assessment
             For the nursing diagnoses that are fully developed, include the following:
             assessments, lab data, diagnostic test results, medications and past
             medical/psych history if appropriate.

          c. Interventions
             State interventions for the nursing diagnoses that are fully developed.
             These interventions should be realistic and individualized to the specific
             patient. Include interventions that you as the nurse would implement.
             Your nursing care plan book is a great resource to find interventions but
             you need to individualize the interventions to your patient. DO NOT
             copy word for word from this text or any other book.
          d. Evaluation (This is the evaluation of the patient goals).
          e. Medication cards or medication sheet. (see the following example)
                     Example of Drug Card:
                     Front of Card should include the following:
                     Classification of Drug:               Route:
                     Mechanism of Action (MOA):
                     Uses and reason patient is receiving:
                     Nursing Implications (When would I question giving this
                     medication?) This will also include route and any special
                     precautions such as IVP and length of time.
                     How will I monitor to see if the drug is working?
                    Back of Card:
                     Side-effects:          Teaching Needs:        Drugs Names:
1/08 JE
1/08 JE

				
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