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 |

| | | | | | |

|History of Present Illness including Admission Diagnosis& |Relevant Diagnostic Procedures/Results & Surgeries |

|Relevant Physical Assessment Findings (normal & abnormal) |(include dates, if not found state so) |

| | |

|Past Medical & Surgical History, |Pertinent Lab tests/ Values (with normal ranges), |

|Pathophysiology of medical diagnoses |with dates and rationales |

|(with APA citations) | |

| | |

|Erikson’s Developmental Stage with Rationale |Socioeconomic/Cultural/Spiritual Orientation |

|(APA citation) |& Psychosocial Considerations |

| | |

|Potential Health Deviations, Predisposing & Related Factors; |Interprofessional Consults, Discharge Referrals, & Current Orders (include diet, test, and |

|Interventions to assess or prevent potential health deviations |treatments) with Rationale |

|(“At Risk for…” nursing dx) (AT LEAST TWO) |(with APA citations) |

| | |

|Prioritized |Nursing Diagnosis |Planning |Prioritized Independent and collaborative |Rationale |Evaluation |

|Gordon’s Functional Health |(at least 2) |(outcome/goal) |nursing interventions; include further |(use APA citations) |Goal Met, Partially Met, |

|Care Patterns | |Measureable goal during your |assessment, intervention and teaching | |or Not Met |

| | |shift |(at least 4 per goal) | |& Explanation |

| | |(at least 1 per Nursing | | | |

| | |diagnosis) | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Current Medications

|Medications (with APA |Class/Purpose |Route |Frequency |Dose (& range) |Mechanism of action |Common side effects |Nursing considerations |

|citations | | | |If out of range, why? |Onset of action | |specific to this client |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

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References

NURSING CARE PLAN RUBRIC

NAME: COURSE: ________DATE: ________________

CLIENT INITIALS: CLIENT DISEASE/DISORDER: _____________________

|Criteria |4 |3 |2 (Approaching Expectations) |1 (Does Not Meet Expectations) |Total Points |

| |(Exceeds Expectations) |(Meets Expectations) | | | |

|1.History of Present Illness, |HPI explained in detail with accurate |HPI explained in some detail with |HPI explained in limited detail with |HPI details limited with poor | |

|Physical Assessment, & |and in-depth understanding of chief |moderate understanding of chief |marginal |understanding of chief complaint and | |

|Diagnostic tests/ procedures |complaint and presenting signs/symptoms |complaint and presenting signs/symptoms|understanding of chief complaint and |presenting signs/symptoms does not | |

| |supported by physical assessment; |somewhat supported by physical |presenting signs/symptoms vaguely |support medical diagnosis, | |

| |identifies 5-6 key assessments |assessment; |supported by physical assessment; |Identifies assessments parameters not| |

| |parameters relevant to medical diagnoses|identifies 3-4 key assessments |identifies 1-2 key assessments |relevant to medical diagnoses, no | |

| |with APA references. |parameters relevant to medical |parameters relevant to medical |references cited. | |

| | |diagnosis with references. |diagnosis, no references cited. | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | |x2 |

|2. Past Medical & Surgical |Past medical history detailed with full|Past medical history given with partial|Past medical history given with |No past medical history given without| |

|History, |explanation of Pathophysiology for each|explanation of identified preexisting |minimal explanation of identified |explanation; no preexisting medical | |

|Pathophysiology |diagnosis & accurate details with |medical diagnoses& explanation accurate|preexisting medical diagnoses & few |diagnosis identified or | |

| |specific detail related to the client’s|with some detail related to the |details related to the client’s |explanations inaccurate and not | |

| |history and symptoms. |client’s history and symptoms. |history and symptoms without |related to the client’s history and | |

| |APA references cited. |References cited |references. |symptoms without references. | |

| | | | | | |

| | | | | |x2 |

|3. Erikson’s Developmental |Identifies and defines correct stage |Identifies and defines correct stage |Identifies correct stage without |Identifies incorrect stage without | |

|Stages & Socioeconomic/ |with examples of meeting/not meeting |with examples of meeting/not meeting |adequate definition or example of |definition or inappropriate examples | |

|Psychosocial Assessment |tasks with APA references. Describes |tasks with references. Describes |meeting/not meeting tasks without |given, no references. | |

| |socioeconomic and cultural background |Socioeconomic and cultural background |references. Describes Socioeconomic |Describes socioeconomic and cultural | |

| |in complete detail. |in some detail. |and cultural background in vague |background with no detail without | |

| |Identifies 3 psychosocial concerns |Identifies 2 psychosocial concerns |detail without references |references | |

| | | |Identifies 1 psychosocial concerns. |Identifies no psychosocial concerns | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | |x2 |

|Criteria |4 |3 |2 (Approaching Expectations) |1 (Does Not Meet Expectations) |Total Points |

| |(Exceeds Expectations) |(Meets Expectations) | | | |

|4. Interprofessional Consults |Lists 3 or more appropriate |Lists 2 appropriate collaborative |Lists 1 appropriate collaborative |Lists inappropriate collaborative | |

|& Discharge Referrals |collaborative issues/concerns |issues/concerns |issue/concern |issues/concerns | |

| |Rationale demonstrates excellent |Rationale demonstrates satisfactory |Rationale demonstrates vague |Rationale demonstrates unsatisfactory| |

| |understanding of interventions |understanding of interventions |understanding of interventions |understanding of interventions | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | |x2 |

|5. Potential Health Deviations|Identifies TWO prioritized risk factors|Identifies 1 prioritized risk factor |Identifies 2 prioritized risk factors |Does not identify prioritized risk | |

| |according to NANDA format& identifies 3|according to NANDA format& identifies 2|but not NANDA format& identifies 1 |factors or signs & symptoms not | |

| |signs and symptoms associated with the |signs and symptoms associated with the |sign or symptom associated with the |identified or not related to “at | |

| |“at risk” diagnosis. |“at risk” diagnosis |“at risk” diagnosis |risk” diagnosis | |

| |Writes 3 independent nursing |Writes 2 independent nursing |Writes 1 independent pertinent |Writes 1 independent intervention | |

| |interventions |interventions |intervention |not pertinent | |

| | | | | | |

| | | | | |x2 |

|6. Gordon’s 11 Functional |Identifies 2 appropriate health care |Identifies 1 appropriate health care |Identifies 2 inappropriate health |Identify 1 inappropriate health care | |

|Health Care Patterns |patterns |patterns |care patterns |patterns | |

| | | | | | |

|7. Priority NANDA Nursing |TWO diagnoses written correctly per |Written correctly without sufficient |Written incorrectly with sufficient |Written incorrectly without | |

|Diagnosis |NANDA format with proper etiology |data to support diagnosis |data to support diagnosis |sufficient data to support diagnosis | |

| |&sufficient data to support diagnosis | | | | |

| | | | | | |

| | | | | |x2 |

|8.Planning/Goals& |Goal is measureable, realistic, |Goal is not measureable, realistic, |Goal is not measureable, not |Goal is not measureable, not | |

|Evaluation |related to the problem; |related to the problem; |realistic, related to the problem; |realistic, not related to the | |

| |Data supports if goal is met, not met |Data somewhat supports if goal is met, |Data vaguely supports if goal is met, |problem; | |

| |with appropriate revisions |not met with appropriate revisions |not met with inappropriate revisions |Data does not support if goal is met,| |

| | | | |not met with | |

| | | | |inappropriate revisions | |

| | | | | |x2 |

|9. Implementation& Rationale |Identifies 4 independent interventions |Identifies 3 independent interventions |Identifies 2 independent interventions|Identifies 1 independent | |

| |with teaching; Scientific rationale is |with teaching; |with teaching; |interventions with teaching; | |

| |supported textbook citation |Scientific rationale is somewhat |Scientific rationale is vaguely |Scientific rationale is not relevant| |

| |[Evidence Base Information] |relevant & supported with citation |relevant & not supported from textbook|¬ supported from textbook | |

| | | | | | |

| | | | | |x2 |

|Criteria |4 |3 |2 (Approaching Expectations) |1 (Does Not Meet Expectations) |Total Points |

| |(Exceeds Expectations) |(Meets Expectations) | | | |

|10. Medications |Lists all MAR medications with relevant|Lists all MAR medications but does not |Lists most of the MAR medications with|Lists some MAR medications but does | |

| |side effects and nursing considerations|include relevant side effects and |relevant side effects and nursing |not include relevant side effects and| |

| |specific to patient and reasons why |nursing considerations specific to |considerations specific to patient and|nursing considerations specific to | |

| |patient is receiving drug. |patient and why patient is receiving |why patient is receiving drug. |patient. | |

| | |drug. | | | |

| | | | | |x2 |

|11. General Organization |Accurate APA format, Appropriate |1-2 APA format errors, |Many APA format errors, |No APA formatting, | |

| |citations & references, |Some citations, references are |Inappropriate citations or |No citations or references included,| |

| |No spelling or grammar errors |appropriate, |references, |many spelling or grammar errors | |

| | |Minimal spelling or grammar errors |Many spelling or grammar errors | | |

| | | | | | |

|TOTAL: | | | | | /80 |

COMMENTS: ___________________________

___________________________

___________________________________________________________________________________________________________________________

STUDENT SIGNATURE: ____ DATE:

INSTRUCTOR SIGNATURE: ___ DATE:

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Signs and

Symptoms

As evidenced by

Related to

Contributing

Factors

Diagnostic

Label

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