University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2021
Views:

323

Pages:

2
Author:

Marin Mason

NURSING CARE PLAN CHEAT SHEET NURSING DIAGNOSIS -Based on assessment findings -Review definition and defining characteristics in Nursing Diagnosis textbook to see if appropriate. -Include r/t etiology (What factors are causing or contributing to the problem?) or risk factors for nsg dx. -R/t factor cannot be a medical dx, diagnostic test or s & symptoms. - AEB symptoms ASSESSMENT DATA (Subjective & Objective) Subjective: list subjective data that supports diagnosi Objective: list related objective data Only list assessment data that we know about this problem for this pt, not ALL assessment data you have GOAL/ EXPECTED OUTCOMES Don’t use goals from Nursing Diagnosis textbook! Instead, ‘flip’ the problem by restating the problem as better (improved) or less of it or none of it. Goal is pt focused. Include time frame (Can be either long or short term goal, don’t have to have both) Pt will have less pain by end of shift AEB… Pt will have no pain in one week AEB… Pt will have improved gas exchange by Wed at 3pm AEB… Goal must be realistic & appropriate for client. Expected outcome tell us how we know goal is achieved. They must be measurable & observable. Usually 2-4 expected outcomes are enough. INTERVENTIONS What actions will nurse take to achieve goal? Fundamentals & Nursing Diagnosis textbooks are good sources for interventions. Need to think critically when deciding which ones you will list on this pt’s care plan. Interventions are nurse focused (these are actions nurse will take) - Must be individualized & realistic (can’t ambulate an immobile pt, If nsg dx is r/t to nutrition or fluids, include foods & beverages pt likes) Interventions need to be: - specific (walk 50 ft, not walk more; administer Ampicillin, notadminister antibiotic), -includes a time frame or frequency (q 2 hr, or daily) - relate to THIS goal/problem No set number of interventions is expected. 12 is too few tho! Probably at least 4- 5. Include interventions that RATIONALE WITH REFERENCE State how this intervention will help reach the goal Textbooks are good sources for this. Paraphrase (put in your own words). Whether paraphrased or a direct quote, each rationale for each intervention must have its source listed after it & in this format: (Ackley & Ladwig, 2017, p. 123) EVALUATION Did all the expected outcomes (AEB) occur? If so, then Goal met AEB … comment on each outcome. Did none of them occur? Then Goal not met AEB… Did some of them occur? Then Goal partially met AEB… Each expected outcome is listed separately. (not lungs clear and RR <30) involve other disciplines: PT, OT, RT, dietary, etc.