Guidelines for Writing Nursing Care Plans Reference: Alfaro, Applying Nursing Diagnosis and Nursing Process These guidelines will be used in instructor’s review of nursing care plans and for student to check for completeness. Care plans will receive a grade of satisfactory or unsatisfactory. Refer to student handbook re: nursing care plans. I. Physical Assessment a. Include with each nursing care plan. Use form distributed in NS 1 for adult patients or form given by your clinical instructor. Use pediatric assessment form from hospital chart for pediatric patients. Use newborn assessment form in this packet. II. Developmental Stage Assessment a. Statement of patient’s stage for age (Erickson). b. Commentary/comparison of your patient to the development stage. III. Cultural/Religious Considerations: a. Relate to patient’s concept of health and present condition. IV. Medication a. Include all medications (I.V. meds, H.S. meds, p.r.n.’s etc.) Lab value appropriate? 1. Remember: oxygen is a medicinal gas. 2. Reference and relate to the patient’s diagnosis. V. Lab Work/Diagnostic Tests a. Each lab value should be researched separately as to the information it provides. (i.e., WBC, RBC, Hgb, Hct) b. Circle or highlight all abnormal values. Relate abnormal values to patient’s condition by using lab book, M/S, OB, and Pediatric textbooks. c. Use Pediatric Lab Values for infants and children. Reference: Pediatric textbook - Appendix. d. For postpartum, lab values must include postpartum labs, blood type and rh, rubella immunity status, and group b strep results. VI. Data Collection a. Subjective and objective data must be included which support the nursing diagnosis except in potential nursing diagnosis. 1. Also include in mini-care plans VII. Nursing Diagnosis a. Actual nursing diagnosis is a three-part statement: Problem + Etiology + Signs and Symptoms present, b. Potential and possible nursing diagnosis is a two-part statement: Problem + Etiology. c. Should be from most current NANDA approved list if possible. d. Should be prioritized if more than one. VIII. Patient Goals (Outcome statements) a. Should be written in patient behavioral terms or as a patient statement and be measurable. b. Should have a time element for evaluation purposes . (When the goal will be evaluated for attainment). c. Should be realistic. d. Should relate to the assessment data/problems of your patient. IX. Nursing Actions/Interventions a. Number and identify those that would reduce or remove the contributing factors (etiology) of the nursing diagnosis. b. Assessment and monitoring of status. c. Use Pediatric text book as major reference for pediatric patients. d. Must be individualized for your patient. X. Rationales a. Number each rationale to correspond with each nursing action. b. Each rationale should be referenced with page number and referenced author’s initials The reference should be written at bottom of page, giving title and author. c. Rationale must come from textbooks, not care plan books. XI. Evaluation a. Should relate to the patient goal, indicating whether goal was met partially or completely, or not met. Should also include the patient’s responses to nursing interventions. If goals partially or not met, determine reason. XII. Reassessment a. Assess which interventions should be continued, discontinued, or any changes. Each care plan to include: 1. Physical assessment (adult or pediatric form) see supplementary handouts. 2. Front information/history sheet 3. Lab values a. Each lab value to be explained, in Na, K, Cl, etc. b. Relate each abnormal value to patient’s diagnosis/problems c. For postpartum, lab values must include postpartum labs, blood type and rh, rubella immunity status, and group b strep results. 4. Medications Each patient medication, no matter what its administration route, should be covered. Each medication has its own specific actions, rationale for use, nursing considerations, and special patient teaching areas. 5. 4 Nursing diagnosis, even if patient was cared for only one day. Each diagnosis will have a minimum of 5 interventions with rationales. Note: 1) When student assigned a Med/Surg or Pediatric patient and cardiopulmonary in the same week, a report on the special area and a care plan with 4 nursing diagnoses will be submitted the following week. 2) When student is assigned her/his OR case study one day and another patient the other day of clinical that week, the care plan must be done on the OR patient, including 4 nursing diagnoses on either pre or post considerations. 3) For postpartum, a major care plan is due after the first postpartum rotation. Use the same forms as for your other care plans. For the physical assessment, use the routine form and the addendum related to postpartum patients. A teaching plan is required as part of this assignment. It should cover the general information needed to provide education to any postpartum patient (not specific to what you covered on your patient). This should not be copied out of your book or any other source as this is plagiarism. References are required. The teaching plan (worth up to 15 points) on the following topics must be turned in as part of this assignment during the first postpartum rotation and includes: Infant feeding Breast care Normal lochia progression Perineal care/incision care Warning signs Nutrition/fluids Resumption of sexual activity/birth control Postpartum emotional adjustment Note: Correct spelling, neatness, and grammar are important in all written projects. Use a dictionary, textbook, and reference book as needed. Spell check and grammar check computer programs are available in NLC.
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