Prioritize interventions in order of performance

Prioritize interventions in order of performance

CHC

Nursing Care Plan

STUDENT NAME: DATE: COURSE:
CLIENT INITIALS: DATE OF ADMISSION: AGE: GENDER:
HT: WT: ALLERGIES:
CODE STATUS:
RACE/ETHNICITY: CULTURAL CONSIDERATIONS:
RELIGION/SPIRITUAL CONSIDERATIONS:
OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES:
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc)

SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics)

I. ADMITTING MEDICAL DIAGNOSIS:
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
II. SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses such as DM, COPD, etc)
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
III. SECONDARY MEDICAL DIAGNOSIS:
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
IV. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)

 

V. PAST MEDICAL/SURGICAL HISTORY:
VI. SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed and explanation)
VII. COMPLICATIONS R/T TO ABOVE:
VIII. CONSULTS: (include date and reason for consult)
IX. DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test, and results)

X. LABS:

Lab Test Purpose Normal Values Client Results Interpretation of Abnormal Labs
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XI. MEDS:

Medication

(Brand and Generic Names)

Classification Prescribed Dose,

Freq, Route

Mechanism of Action Patient Specific Indications

 

Side effects/Nursing Implications
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XII. IV FLUIDS: Solution Rate Tonicity
XIII. IV SITE(S):

XIV. PT/OT
XV. RESP TX: Frequency Type Rationale
XVI. NURSING INTERVENTIONS: (frequency, type, description, and/or N/A)

 

VS: date/time temp /route bp p r
 

 

 

 

 

 

 

 

 

 

 

 

Pain level: 0-10 scale Location PQRST
Neuro checks:
Cardiac monitor: Pacemaker/ICD: Hemodynamic monitoring:
Oxygenation: Method of Delivery Flow Rate Pulse Oximetry
Vent settings: Mode TV FiO2 Rate PEEP/CPAP
ABGs: Suctioning: Method Frequency Result
Nutrition:

Weight:

Diet Appetite Tolerance Wt gain/loss Dentition Chewing/

Swallowing

Enteral feeding: Route Indication Formula Rate Tolerance
 

 

 

 

 

Glucose (FS or lab)
Bowel/bladder elimination: I&O:
Foley NG Ostomy Drains Other tubes
Dressing/wound care: Location Appearance
Mobility:
Ortho: (traction, cast, etc) Activity/assistive aids:
Safety considerations: Restraints: (date, type and justification)
Sleep/rest:

Hours Quality Aides

XVII. HEAD-TO-TOE ASSESSMENT:

Neuro:

HEENT:

Resp:

C/V:

GI:

GU:

Reproductive: (Maternal to include breasts, fundus, peritoneum, and lochia)

M/S:

Skin/hair/nails:

Psychosocial: (include affect)

XVIII. NURSING DIAGNOSES: (minimum of 5, prioritized)

1.

2.

3.

4.

5.

XIX. NURSING CARE PLANDirections:

1. Formulate a NCP using (3) nursing diagnoses:

a. Two (2) are the priority nursing diagnoses from the above list.

b. The 3rd nursing diagnosis is always Knowledge Deficit.

c. Write full nursing diagnoses statements.

Example: Ineffective airway clearance R/T increased sputum production as evidenced by ineffective cough and coarse rhonchi.

Note: if nursing diagnosis is “Risk for” there is no evidence to report.

d. Include client’s level on Maslow’s Hierarchy.

2. Outcomes:

a. Include Nursing Outcome Classification (NOC).

b. State (2) STGs and (1) LTG.

c. Goals must be client-centered, specific, measurable, realistic, and have a time frame for achievement.

Examples: STG: Lungs will be clear in 8 hours. LTG: Client will demonstrate colostomy care by time of D/C.

Note: Sometimes it is more appropriate for LTGs to extend beyond D/C.

3. Interventions:

a. Include Nursing Intervention Classification (NIC).

b. Prioritize interventions in order of performance.

c. Must be individualized/specific/with frequencies/and be directly related to goals.

d. Cite work for all interventions

Example: 1. Observe/assess resp status for rate, depth, and chest wall movement Q4 hrs and PRN (Lemone & Burke, 2004)

4. Rationales: Specific to each intervention listed and scientific.

Example: 1. Tachypnea, shallow resp, and asymmetric chest movement may be indicative of resp compromise (Lemone & Burke, 2004).

Note: Use nursing textbooks and scholarly journals only.

No medical dictionaries or health-related internet web sites are to be used.

Cite work for all rationales.

Note: Last page of NCP must include APA formatted reference page for all works cited in interventions and rationales.

5. Documentation: Document your interventions as you would in written nurses’ notes. Example: 0800 RR shallow at 24/min, even, non-labored.

6. Evaluation: Evaluate each STG as met, partially met, or not met and care plan status as D/C, continue, or revise.

Example: Goal not met. Revise care plan. Note for teaching care plan: In order for learning to have taken place, the client must verbalize or demonstrate something.

Example: Verbalized how to read labels on canned goods for sodium content.

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

 

INTERVENTIONS

 

RATIONALES DOCUMENTATION

 

EVALUATION
  NOC: NIC:

 

 

 

 

Maslow’s Hierarchy Level:

 

 

 

 

 

 

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

 

INTERVENTIONS

 

RATIONALES DOCUMENTATION

 

EVALUATION
  NOC: NIC:

 

 

 

 

Maslow’s Hierarchy Level:

 

 

 

 

 

 

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

 

INTERVENTIONS

 

RATIONALES DOCUMENTATION

 

EVALUATION
  NOC: NIC:

 

 

 

 

Maslow’s Hierarchy Level:

 

 

 

 

 

 

PBVI 9.12.12

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