Nursing Care Plan

Nursing Care Plan

Student Course Date
Instructor
Patient Initial _____________ Age _______________ Height/Weight
Unit Room#
Code Status_____________ Allergies_____________________________________________________________________________________

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
36.90 c 112 beats/minute 28 breaths/minute Systolic is 107 mm HG and Diastolic is 44 mm HG Systolic-diastolic=blood pressure
107-44= 63
63 mm HG 4

History of Present Illness including Admission Diagnosis
Relevant Physical Assessment Findings(normal & abnormal) Relevant Diagnostic Procedures/Results & Surgeries
(include dates, if not found state so)
Normal: maturity at birth 9 nine months(36 weeks) and average if 370 c
Abnormal: Alicia was born prematurely at 32 weeks(one month earlier than her term) and temperature was 400 c(3 degrees higher)
(Price Debra, 2007) 4/30/11-5/9/11 admitted for r/o line sepsis and parental training
4/14-4/17/11 admitted for broken PICC line, Broviac replaced 4/16 (epistaxis, coagulopathic got increased Vit K x 3d)
4/3-4/11/11 admitted for observation, pt had 3d diarrhea. Blood/stool cx were negative.
3-4-4/23/11 pt was febrile, diagnosed klebsialla oxytoca PNA line infection, Broviac broke, PICC placed 3/8/11
12/8/-12/28/10 admitted fever dx klebsialla oxytoca and E coli infection, 12/12 grew CONS (Deanna, 2011)
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(with APA citations) Pertinent Lab tests/ Values (with normal ranges),
with dates and rationales
Past medical: Gastroschisis,> 10 abdominal surgeries, short gut (with aprox 27 cm bowel with ileocecal valve as of Oct 2010; s/p TPN cholestasis (now s/p Omegavan study, had liver/multivisceral transplant evaluation at CHLA Oct 2010-currently resolved and usually TB; developmental delay; CLD- prematurity, albuterol Q6hr, pulmicort QD; s/p duodenal muccocutaneous fistula now resolved; and s/p sepsis klebsialla 3/4/11 and CONS.
Past surgical: primary closure of gastroschisis (May 2010), development of NEC requiring repeat surgical explorations with silo placement with extensive adhesionlysis on last surgery(June 2010), mucous fistula/ ostomy creation (June 2010), GT placement (Aug 2010)with subsequent development of duodenalcutaneos fistula; and fistula closure and JT placement (Sept 2010)- > JT currently removed (Axton Sharon, 2003) RBC: 3.95 MCHC: 33.8
MCV: 79.5 MPV: 10.4
MCH: 26.8 RDW-CV: 14.1
O6/14 13:00
Urinalysis
UA Specimen: Urine
UA Color: yellow
UA Appearance: Clear
UA Glucose: Negative
UA Reduce Subs: Not Indicated(normal low)
UA Bilirubin: Negative
UA Ketones: Negative
UA Sp Gravity: 1.015
UA Occult Blood: Negative
UA pH: 7.0
UA Protein
UA Urobilinogen: 0.2 E.U./dL
UA Nitrite: Negative
UA Leuk Estrase: Negative
Differential Manual
Seg% M: 63 %
Band % M: 4 %
Lymph% M: 22 %
Mono% M: 11 %
Eos% M: 0 %
Manual NRBC: 0 Per 100 WBC
Abs Neut Calculated: 8.91
Red Cell Morphology
Polychromasia: Slight/Few
Burr Cell: Slight? Few
Ovalocytosis: Slight/Few
Erikson’s Developmental Stage with Rationale
(APA citation) Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations
Potential Health Deviations, Predisposing &Related Factors;
Interventions to assess or prevent potential health deviations
(“At Risk for…” nursing dx) (AT LEAST TWO) Interprofessional Consults, Discharge Referrals, & Current Orders(include diet, test, and treatments) with Rationale
(with APA citations)
Prioritized
Gordon’s Functional Health Care Patterns
Nursing Diagnosis
(at least 2)
Planning
(outcome/goal)
Measureable goal during your shift
(at least 1 per Nursing diagnosis)
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal) Rationale
(use APA citations) Evaluation
Goal Met, partially met,
or not Met
& Explanation

 

Current Medications
Medications (with APA citations Class/Purpose Route Frequency Dose(& range)
If out of range, why? Mechanism of action
Onset of action Common side effects Nursing considerations
Specific to this client

References
Axton Sharon, F. (2003). Pediatric nursing care plans. New Jersey: Prentice Hall.
Deanna, O. (2011). Sanchezalvarez,Alicia. History & Physical (IP Physician) , 4 pages.
Price Debra, G. (2007). Pediatric Nursing: An Introductory Tex. Missouri: Elsevier Health Sciences.

NURSING CARE PLAN RUBRIC
NAME: COURSE: ________DATE: ________________

CLIENT INITIALS: CLIENT DISEASE/DISORDER: _____________________

SCALE 4 (Excellent) 3 ( Good) 2 (Minimally Competent) 1 (Unacceptable)
CRITERIA 10 8 5 3 POINTS
1.History of Present Illness, Physical Assessment, &
Diagnostic tests/ procedures
HPI explained in detail with accurate and in-depth understanding of chief complaint and presenting signs/symptoms supported by physical assessment;
identifies 5-6 key assessments parameters relevant to medical diagnoses with APA references. HPI explained in some detail with moderate understanding of chief complaint and presenting signs/symptoms somewhat supported by physical assessment;
identifies 3-4 key assessments parameters relevant to medical diagnosis with references. HPI explained in limited detail with marginal
understanding of chief complaint and presenting signs/symptoms vaguely supported by physical assessment;
identifies 1-2 key assessments parameters relevant to medical diagnosis, no references cited. HPI details limited with poor understanding of chief complaint and presenting signs/symptoms does not support medical diagnosis,
Identifies assessments parameters not relevant to medical diagnoses, no references cited.
2. Past Medical & Surgical History,
Pathophysiology

Past medical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms.
APA references cited. Past medical history given with partial explanation of identified preexisting medical diagnoses& explanation accurate with some detail related to the client’s history and symptoms.References cited Past medical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms without references. No past medical history given without explanation; no preexisting medical diagnosis identified or
explanations inaccurate and not related to the client’s history and symptoms without references.
3. Erikson’s Developmental Stages & Socioeconomic/
Psychosocial Assessment
Identifies and defines correct stage with examples of meeting/not meeting tasks with APA references. Describes socioeconomic and cultural background in complete detail.
Identifies 3 psychosocial concerns Identifies and defines correct stage with examples of meeting/not meeting tasks with references. Describes
Socioeconomic and cultural background in some detail.
Identifies 2 psychosocial concerns Identifies correct stage without adequate definition or example of meeting/not meeting tasks without references. Describes Socioeconomic and cultural background in vague detail without references
Identifies 1 psychosocial concerns Identifies incorrect stage without definition or inappropriate examples given, no references.
Describes socioeconomic and cultural background with no detail without references
Identifies no psychosocial concerns

SCALE 4( Excellent) 3 (Good) 2 (Minimally Competent) 1 (Unsatisfactory)
CRITERIA 10 8 5 3 POINTS
4. Multidisciplinary Consults & Discharge Referrals Lists 3 or more appropriate collaborative issues/concerns
Rationale demonstrates excellent understanding of interventions Lists 2 appropriate collaborative issues/concerns
Rationale demonstrates satisfactory understanding of interventions Lists 1 appropriate collaborative issue/concern
Rationale demonstrates vague understanding of interventions Lists inappropriate collaborative issues/concerns
Rationale demonstrates unsatisfactory understanding of interventions
5. Potential Health Deviations Identifies TWO prioritized risk factors according to NANDA format& identifies 3 signs and symptoms associated with the “at risk” diagnosis.
Writes 3 independent nursing interventions Identifies 1 prioritized risk factor according to NANDA format& identifies 2 signs and symptoms associated with the “at risk” diagnosis
Writes 2 independent nursing interventions Identifies 2 prioritized risk factors but not NANDA format& identifies 1 sign or symptom associated with the “at risk” diagnosis
Writes 1 independent pertinent intervention Does not identify prioritized risk factors or signs & symptoms not identified or not related to “at risk” diagnosis
Writes 1 independent intervention not pertinent
CRITERIA 5 3 2 1 POINTS
6. Gordon’s 11 Functional Health Care Patterns Identifies 2 appropriate health care patterns Identifies 1 appropriate health care patterns Identifies 2 inappropriate health care patterns Identify 1 inappropriate health care patterns

CRITERIA 10 8 5 3 POINTS
7. Priority NANDA Nursing Diagnosis
TWO diagnoses written correctly per NANDA format with proper etiology &sufficient data to support diagnosis Written correctly without sufficient data to support diagnosis Written incorrectly with sufficient data to support diagnosis Written incorrectly without sufficient data to support diagnosis
8.Planning/Goals&
Evaluation
Goal is measureable, realistic, related to the problem;
Data supports if goal is met, not met with appropriate revisions Goal is not measureable, realistic, related to the problem;
Data somewhat supports if goal is met, not met with appropriate revisions Goal is not measureable, not realistic, related to the problem;
Data vaguely supports if goal is met, not met with inappropriate revisions Goal is not measureable, not realistic, not related to the problem;
Data does not support if goal is met, not met with
inappropriate revisions
SCALE 4 (Excellent) 3 (Good) 2 (Minimally Competent) 1 (Unsatisfactory)
CRITERIA 10 8 5 3 POINTS
9. Implementation &Rationale
Identifies 4 independent interventions with teaching; Scientific rationale is supported textbook citation
[Evidence Base Information] Identifies 3 independent interventions with teaching;
Scientific rationale is somewhat relevant & supported with citation Identifies 2 independent interventions with teaching;
Scientific rationale is vaguely relevant & not supported from textbook Identifies 1 independent interventions with teaching; Scientific rationale is not relevant & not supported from textbook
10. Medications
Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug. Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug. Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug. Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient.
CRITERIA 5 4 3 1 POINTS
11. General Organization
Accurate APA format, Appropriate citations &references,
No spelling or grammar errors 1-2 APA format errors,
Some citations, references are appropriate,
Minimal spelling or grammar errors Many APA format errors,
Inappropriate citations or references,
Many spelling or grammar errors No APA formatting,
No citations or references included, many spelling or grammar errors
TOTAL:

COMMENTS:
STUDENT SIGNATURE: ____ DATE:
INSTRUCTOR SIGNATURE: ___ DATE:

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