According to the last two groups that Robin and

							Mendocino College
Registered Nursing Program


Nursing Care Plan Expectations
Nursing care plans are meant to be a learning tool. As your faculty, we are particularly interested in how
you synthesize all aspects of the patient’s care into a cohesive plan that prioritizes the patient’s needs
accurately.

Patient Information:
    1. In nursing, when filling out a form, there should be something listed for every box/section of the
        care plan. The reasoning behind this is that it is assumed that “if you did not list anything, you
        did not think about it”. As we all have come to know and despise at times, documentation is as
        important as thinking about it. “If you didn’t document it, you didn’t do it.” To help you prepare
        for this requirement of nurses everywhere, you must complete each section of the patient care
        form.
            a. Example: If your patient is 45 years old, clearly no geriatric assessment for ADLs is
                 necessary because of his young age. In that box, you can write, “N/A”. This simple
                 “N/A” acknowledges that you thought about his/her age and mobility/ADLs and were
                 able to determine that an evaluation was not necessary.
            b. Example: Intake/Output- some patients/nurses are not maintaining strict I’s and O’s. You
                 can write: “N/A- no fluid restrictions” or “N/A- voiding to toilet ad lib”
    2. Remember the Vital Signs section is reporting parameters- not the last set of vital signs that you
        took.

Diagnostic Testing:
   1. All testing that pertains to the primary diagnosis as well as other medical issues that affect the
       patient’s well being should be included.
           a. Once you are the primary nurse, you may be responsible for explaining the test procedure
                to them and their families. Use this time as a student to really understand the tests that
                your patients are undergoing.

Laboratory Data:
This section shows us as instructors that you know what labs to look at in relation to your patient’s
diagnosis. Even if the value is normal, it may be pertinent to include in your analysis.
    1. Please include entire basic metabolic panel- even if normal.
            a. The reasoning behind this is that as nurses, you are expected to have these normal values
               memorized. The more practice you have writing these numbers down, the easier it will
               be to memorize.
            b. BMP includes: Na+, K+, Cl-, HCO3-, BUN, Cr, and glucose.
    2. Please include at least these parts of the CBC:
            a. WBCs, RBC, Hgb, Hct, MCV, Platelets- even if normal.
            b. Include any other aspects of the CBC if abnormal.
            c. Reasoning- again, these are values you will be required to memorize. The more you
               understand what these values mean, the easier it will be to synthesize the most important
               needs of your patient. Remember anemia and infection are very common regardless of
               what field of nursing you enter.
            d. Also, think your patient’s diagnosis through! If your patient was admitted for an
               infection, it makes sense to include the differential of the CBC in your report because the
               differential more clearly shows the values for specific types of infections (allergies,
               bacterial, viral, parasitic).



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Mendocino College
Registered Nursing Program

           e. Example: Including the PT/PTT/INR values (regardless of if they are normal or
               therapeutic) when your patient has atrial fibrillation shows us that you have made the
               connection that atrial fibrillation can cause thrombus which can lead to strokes or
               pulmonary emboli, etc.
    3. Include the lab values that pertain to your patient’s diagnosis- even if normal.
           a. Normal values show that the corrections for which they were admitted to the hospital are
               occurring- which is a very important assessment. Your patient is getting better!
                    i. Example: Troponin is a protein unique to the cardiomyocytes. When the cardiac
                        muscle tissue is damaged, this protein is released from 1hr to 15 days post-injury.
                        If someone is admitted with chest pain for rule out myocardial infarction,
                        including the troponin values (even if normal) is essential for your assessment of
                        your patient’s condition.

Medications:
  1. Remember to list out side effects for each medication. It’s a good reminder while you still have
      the time to do these reviews!
  2. If you are not sure, please look them up! Do not take the chance of listing incorrect side effects
      and drug actions, now is the time to learn this stuff before you have five patients and a tight
      schedule for which to learn your medications.
  3. Also remember, college is a time to “learn how to learn”. As nurses, this becomes even more
      important. Utilize this time! Once you are nursing, you will still have to be learning but, you
      may have an easier time at it because of all the work you put into while in school.

Brief Patient Admission History:
    1. Please include all diagnoses,
    2. List whether or not the patient is on telemetry
    3. How the patient ended up in the hospital (history of present illness)

Nursing Diagnoses:
When thinking through your nursing diagnoses,
   1. Synthesize your patient’s lab data, diagnostic tests, medical diagnoses, psychosocial needs and
       medication
   2. What is going to compromise this patient first?
           a. Remember ABCs (airway, breathing, circulation)
           b. Identify their most pressing, important problem- in your own words
           c. Then find a corresponding nursing diagnosis
                    i. Example: If your patient is breathing fine, talking to you and taking their
                       medications but has dilated cardiomyopathy and congestive heart failure, then we
                       know that they have decreased cardiac output and can formulate a plan of care
                       around that.
                   ii. Sometimes it is hard to find a corresponding nursing diagnosis for your
                       assessment, don’t get discouraged, keep looking, it’s there!
                           1. Example: Respiratory Acidosis relates to Gas Exchange, Impaired.
   3. Short vs. Long term goals
           a. There is not a set prescription for how to determine a short or long term goal, what’s
               important is your thinking behind the goals and interventions.
                    i. Example: You may have goals just for today and goals to attain by date of
                       discharge. Or you may have short term goals to attain by discharge (like
                       hemodynamically stable) but more long term goals like proper care at home or
                       teaching etc.



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Mendocino College
Registered Nursing Program

                   ii. The decision of how to formulate your goals is based upon your assessment of
                       your patient.
                  iii. Remember: be specific, be realistic, be measurable, indicate a time frame for
                       achieving goals, consider patient’s desires and resources
   4. Interventions
          a. 5 MINIMUM interventions for each goal
          b. Do not use sentence form, just write out the actions that you will take
          c. The NIC project has identified over 486 interventions (like respiratory monitoring) to
              utilize so; use your nursing care plan resources if you feel stuck!




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