Care plan

NURSING PROCESS CAREPLAN

MEDICAL PREP INSTITUTE OF TAMPA BAY

COURSE NAME:

INSTRUCTOR:

STUDENT NAME:

ASSIGNMENT DATE:

MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan

Client Initials: Culture/Ethnicity: Support System:

Unit: Room/Bed: Religion: Occupation:

Age: Sex: Language: Current Work Status:

Weight: Height: Marital Status: Highest Grade Completed:

Primary Patient Complaint: Patient Medical History:

Diagnostic Procedures (Not to include labs):

Surgical Procedures:

Pathophysiology/Etiology (Theory): Define patient primary problem and cause(s).

Supporting Symptomatology: What patient data supports your selection of Pathophysiology?

Developmental Stage (Theory): Utilize Erikson. Identify what stage is applicable to your patient based on their age.

Developmental Stage (Actual): Identify what developmental stage your patient is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage.

Vital Signs/Frequency:

LAB RESULTS INTERPRETATION

PATIENT’S LAB RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS

DIAGNOSTIC RESULTS INTERPRETATION

PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS

ASSESSMENT Subjective/ Objective

NURSING DIAGNOSIS

#1 (Physical)

PLANNING/ OUTCOME

(Client Centered) 1 Short Term 1 Long Term

INTERVENTIONS (Nurse Centered)

1 Monitoring, 1 Action & 1 Teaching per Goal

RATIONALE FOR INTERVENTIONS

1 per Intervention

EVALUATION (Evaluate each

Goal)

ASSESSMENT Subjective/ Objective

NURSING DIAGNOSIS

#2 (Physical)

PLANNING/ OUTCOME

(Client Centered) 1 Short Term 1 Long Term

INTERVENTIONS (Nurse Centered)

1 Monitoring, 1 Action & 1 Teaching per Goal

RATIONALE FOR INTERVENTIONS

1 per Intervention

EVALUATION (Evaluate each

Goal)

ASSESSMENT Subjective/ Objective

NURSING DIAGNOSIS

#3 (Psychosocial)

PLANNING/ OUTCOME

(Client Centered) 1 Short Term 1 Long Term

INTERVENTIONS (Nurse Centered)

1 Monitoring, 1 Action & 1 Teaching per Goal

RATIONALE FOR INTERVENTIONS

1 per Intervention

EVALUATION (Evaluate each

Goal)

STUDENT NAME:

Medication #1:

Classification of Medication:

Trade Name:

Generic Name:

Dosage:

Dosage Forms: Routes:

Why is THIS patient SPECIFICALLY receiving this medication?

Side effects/Adverse reactions: Lab Values:

CONTRAINDICATIONS:

Nursing Implications/Responsibilities:

STUDENT NAME:

Medication #2:

Classification of Medication:

Trade Name:

Generic Name:

Dosage:

Dosage Forms: Routes:

Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication)

Side effects/Adverse reactions: Lab Values:

CONTRAINDICATIONS:

Nursing Implications/Responsibilities:

STUDENT NAME:

Medication #3:

Classification of Medication:

Trade Name:

Generic Name:

Dosage:

Dosage Forms: Routes:

Why is THIS patient SPECIFICALLY receiving this medication?

Side effects/Adverse reactions: Lab Values:

CONTRAINDICATIONS:

Nursing Implications/Responsibilities:

STUDENT NAME:

Medication #4:

Classification of Medication:

Trade Name:

Generic Name:

Dosage:

Dosage Forms: Routes:

Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication)

Side effects/Adverse reactions: Lab Values:

CONTRAINDICATIONS:

Nursing Implications/Responsibilities:

STUDENT NAME:

Medication #5:

Classification of Medication:

Trade Name:

Generic Name:

Dosage:

Dosage Forms: Routes:

Why is THIS patient SPECIFICALLY receiving this medication?

Side effects/Adverse reactions: Lab Values:

CONTRAINDICATIONS:

Nursing Implications/Responsibilities:

MEDICAL PREP INSTITUTE OF TAMPA BAY

Nursing Process Care Plan

References Page

1.

2.

3.

MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan

GRADING RUBRIC GRADE: /9

Student Name: _____________________________________________ Course Name: ______________________________________________

Category

Excellent

1 Point

Good

0.75 Points

Fair

0.50 Points

Poor /

Incomplete

0.25 Pts –

0 Pts

PATIENT DEMOGRAPHIC PAGE

Accurate and thorough Patient Demographic Pg: Pt. Primary Complaint, Medical Hx, Dx Proc, Surgical Proc.,

Pathophys., Devel Stage, etc.

Patient Demographic Page is included, but missing one

element.

Patient Demographic Page is included, but missing several

elements.

Pt. demographic is incomplete,

missing or inappropriate to

patient.

LABS & DIAGNOSTICS Includes labs and diagnostics appropriate to

patient & patient’s disease process

Includes complete labs and diagnostics sheet related to & appropriate to patient’s

disease process: specific, & correctly labeled.

Contains adequate number of Labs/Diagnostics related

to & appropriate to patient’s disease process,

but labs & diagnostics may not be specific or correctly

labeled.

Does not contain adequate number of Labs/ Diagnostics related to & appropriate to

patient’s disease process, and may not be specific, labeled

or listed with rationales.

Labs & Diagnostics portion is

incomplete, missing or

inappropriate to patient.

ASSESSMENT Includes subjective, objective and historical data that support actual or risk for nursing

diagnosis.

Includes all pertinent data related to nursing diagnosis

and does not include data that is not related to

nursing diagnosis.

Includes all pertinent data related to nursing

diagnosis, but also includes data not related to nursing

diagnosis.

Does not include all pertinent data related to nursing

diagnosis. May also include data that does not relate to

nursing diagnosis.

Assessment portion is

incomplete, missing or

inappropriate to patient.

DIAGNOSIS Includes the most appropriate diagnosis for patient and ordinal number that includes all appropriate parts (stem, related to or R/T,

and as evidenced by AEB for actual diagnosis) and is NANDA approved.

(2 Physical & 1 Psychosocial)

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved. Diagnosis also

includes all parts and information is listed in

correct part of diagnosis.

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved, but does not

include all parts or information is listed in

wrong part of diagnosis.

Diagnosis is not appropriate for patient and ordinal level

(first diagnosis, second diagnosis, etc.). May also not

be NANDA and may not include all parts.

Diagnosis portion is

incomplete, missing or

inappropriate to patient.

PLANNING (Goal Setting) Includes a patient or family goal that is most appropriate for the patient/family and the nursing diagnosis. Goal should be realistic and measurable by at least two criteria

and have a target date or time.

Goal statement is patient or

family oriented, and

contains two measurable

and realistic criteria and a

target date or time.

Goal statement is patient or family oriented, and contains at least one

measurable and realistic criteria or a target

date/time.

Goal statement is not patient or family oriented and may

not have measurable and/ or realistic criteria or a target

date or time.

Goal portion is incomplete, missing or

inappropriate to patient.

IMPLEMENTATION (Interventions) Includes 3 interventions or nursing actions that directly relate to the patient's goal, that are specific in action and frequency, consist of 1 monitoring, 1 action and 1 teaching

intervention. Interventions should be appropriate to help patient or family meet

their goal.

Interventions portion contains adequate number

of interventions to help patient/family meet goal,

and interventions are specific in action and

frequency, consist of 1 monitoring, 1 action and 1 teaching intervention and

are listed with appropriate rationales.

Interventions portion contains adequate number

of interventions to help patient/family meet goal, but interventions may not

be specific, labeled or listed with appropriate rationales.

Interventions portion does not include adequate number

of interventions to help patient/family meet goal.

Interventions may also not be specific, labeled or listed with appropriate rationales.

Interventions portion is

incomplete, missing or

inappropriate to patient.

EVALUATION Includes data that is listed as criteria in goal

statement. Based on this data, goal is determined to be met, partially met, or not

met. If goal was not met or partially met, plan of care is revised or continued and a

new evaluation date/time is set.

Evaluation portion does contain data that is listed as

criteria in goal statement. Does describe goal as met, partially met, or not met. If goal was partially met or

not met, includes revision and/or new evaluation

date/time.

Evaluation portion does contain data that is listed as

criteria in goal statement, but does not describe goal

as met, partially met, or not met. May also not include

revision or new evaluation date/time.

Evaluation portion does not contain data that is listed as

criteria in goal statement. May also not describe goal as

met, partially met, or not met. May also not include

revision or new evaluation date/time.

Evaluations portion is

incomplete, missing or

inappropriate to patient.

DRUG CARDS Includes at least 5 drug cards appropriate

to patient, complete and accurately selected.

Includes 5 or more drug cards related to and

appropriate to patient’s disease process.

Includes at least 4 drug cards related to patient’s

disease process.

Includes at least 3 drug cards related to patient’s disease

process.

Drug Cards are incomplete or

missing.

Additional Criteria: (Total 1 point) ⃝ Paper is Typed. ⃝ Spelling Correct. ⃝ Neat. ⃝ At least 3 References in proper APA Format.

1. STUDENT NAME:
2. COURSE NAME:
3. INSTRUCTOR:
4. ASSIGNMENT DATE:
5. Client Initials:
6. CultureEthnicity:
7. Support System:
8. Unit:
9. RoomBed:
10. Religion:
11. Occupation:
12. Age:
13. Sex:
14. Language:
15. Current Work Status:
16. Weight:
17. Height:
18. Marital Status:
19. Primary Patient Complaint:
20. Patient Medical History:
21. Diagnostic Procedures Not to include labs:
22. Surgical Procedures:
23. PathophysiologyEtiology Theory Define patient primary problem and causes:
24. Supporting Symptomatology What patient data supports your selection of Pathophysiology:
25. Developmental Stage Theory Utilize Erikson Identify what stage is applicable to your patient based on their age:
26. Developmental Stage Actual Identify what developmental stage your patient is ACTUALLY in Describe behaviorsconcerns that support your selection of this Developmental Stage:
27. Vital SignsFrequency:
28. PATIENTS LAB RESULTSRow1:
29. NORMAL RANGERow1:
30. NURSING INTERVENTIONS AND ACTIONSRow1:
31. PATIENTS LAB RESULTSRow2:
32. NORMAL RANGERow2:
33. NURSING INTERVENTIONS AND ACTIONSRow2:
34. PATIENTS LAB RESULTSRow3:
35. NORMAL RANGERow3:
36. NURSING INTERVENTIONS AND ACTIONSRow3:
37. PATIENTS LAB RESULTSRow4:
38. NORMAL RANGERow4:
39. NURSING INTERVENTIONS AND ACTIONSRow4:
40. PATIENTS LAB RESULTSRow5:
41. NORMAL RANGERow5:
42. NURSING INTERVENTIONS AND ACTIONSRow5:
43. PATIENTS DIAGNOSTIC RESULTSRow1:
44. NORMAL RANGERow1_2:
45. NURSING INTERVENTIONS AND ACTIONSRow1_2:
46. PATIENTS DIAGNOSTIC RESULTSRow2:
47. NORMAL RANGERow2_2:
48. NURSING INTERVENTIONS AND ACTIONSRow2_2:
49. PATIENTS DIAGNOSTIC RESULTSRow3:
50. NORMAL RANGERow3_2:
51. NURSING INTERVENTIONS AND ACTIONSRow3_2:
52. PATIENTS DIAGNOSTIC RESULTSRow4:
53. NORMAL RANGERow4_2:
54. NURSING INTERVENTIONS AND ACTIONSRow4_2:
55. PATIENTS DIAGNOSTIC RESULTSRow5:
56. NORMAL RANGERow5_2:
57. NURSING INTERVENTIONS AND ACTIONSRow5_2:
58. ASSESSMENT Subjective ObjectiveRow1:
59. ASSESSMENT Subjective ObjectiveRow2:
60. NURSING DIAGNOSIS 1 PhysicalRow1:
61. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow1:
62. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow1:
63. RATIONALE FOR INTERVENTIONS 1 per InterventionRow1:
64. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow2:
65. RATIONALE FOR INTERVENTIONS 1 per InterventionRow2:
66. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow3:
67. RATIONALE FOR INTERVENTIONS 1 per InterventionRow3:
68. EVALUATION Evaluate each GoalRow1:
69. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow2:
70. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow4:
71. RATIONALE FOR INTERVENTIONS 1 per InterventionRow4:
72. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow5:
73. RATIONALE FOR INTERVENTIONS 1 per InterventionRow5:
74. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow6:
75. RATIONALE FOR INTERVENTIONS 1 per InterventionRow6:
76. EVALUATION Evaluate each GoalRow2:
77. ASSESSMENT Subjective ObjectiveRow1_2:
78. ASSESSMENT Subjective ObjectiveRow2_2:
79. NURSING DIAGNOSIS 2 PhysicalRow1:
80. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow1_2:
81. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow1_2:
82. RATIONALE FOR INTERVENTIONS 1 per InterventionRow1_2:
83. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow2_2:
84. RATIONALE FOR INTERVENTIONS 1 per InterventionRow2_2:
85. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow3_2:
86. RATIONALE FOR INTERVENTIONS 1 per InterventionRow3_2:
87. EVALUATION Evaluate each GoalRow1_2:
88. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow2_2:
89. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow4_2:
90. RATIONALE FOR INTERVENTIONS 1 per InterventionRow4_2:
91. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow5_2:
92. RATIONALE FOR INTERVENTIONS 1 per InterventionRow5_2:
93. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow6_2:
94. RATIONALE FOR INTERVENTIONS 1 per InterventionRow6_2:
95. EVALUATION Evaluate each GoalRow2_2:
96. ASSESSMENT Subjective ObjectiveRow1_3:
97. ASSESSMENT Subjective ObjectiveRow2_3:
98. NURSING DIAGNOSIS 3 PsychosocialRow1:
99. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow1_3:
100. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow1_3:
101. RATIONALE FOR INTERVENTIONS 1 per InterventionRow1_3:
102. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow2_3:
103. RATIONALE FOR INTERVENTIONS 1 per InterventionRow2_3:
104. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow3_3:
105. RATIONALE FOR INTERVENTIONS 1 per InterventionRow3_3:
106. EVALUATION Evaluate each GoalRow1_3:
107. PLANNING OUTCOME Client Centered 1 Short Term 1 Long TermRow2_3:
108. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow4_3:
109. RATIONALE FOR INTERVENTIONS 1 per InterventionRow4_3:
110. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow5_3:
111. RATIONALE FOR INTERVENTIONS 1 per InterventionRow5_3:
112. INTERVENTIONS Nurse Centered 1 Monitoring 1 Action 1 Teaching per GoalRow6_3:
113. RATIONALE FOR INTERVENTIONS 1 per InterventionRow6_3:
114. EVALUATION Evaluate each GoalRow2_3:
115. STUDENT NAME_2:
116. Medication 1:
117. Classification of Medication:
118. Trade Name:
119. Generic Name:
120. Dosage:
121. Dosage Forms:
122. Routes:
123. Why is THIS patient SPECIFICALLY receiving this medication:
124. Side effectsAdverse reactions:
125. Lab Values:
126. CONTRAINDICATIONS:
127. Nursing ImplicationsResponsibilitiesRow1:
128. STUDENT NAME_3:
129. Medication 2:
130. Classification of Medication_2:
131. Trade Name_2:
132. Generic Name_2:
133. Dosage_2:
134. Dosage Forms_2:
135. Routes_2:
136. Why is THIS patient SPECIFICALLY receiving this medication Include the action of medication:
137. Side effectsAdverse reactions_2:
138. Lab Values_2:
139. CONTRAINDICATIONS_2:
140. Nursing ImplicationsResponsibilities:
141. STUDENT NAME_4:
142. Medication 3:
143. Classification of Medication_3:
144. Trade Name_3:
145. Generic Name_3:
146. Dosage_3:
147. Dosage Forms_3:
148. Routes_3:
149. Why is THIS patient SPECIFICALLY receiving this medication_2:
150. Side effectsAdverse reactions_3:
151. Lab Values_3:
152. CONTRAINDICATIONS_3:
153. Nursing ImplicationsResponsibilitiesRow1_2:
154. STUDENT NAME_5:
155. Medication 4:
156. Classification of Medication_4:
157. Trade Name_4:
158. Generic Name_4:
159. Dosage_4:
160. Dosage Forms_4:
161. Routes_4:
162. Why is THIS patient SPECIFICALLY receiving this medication Include the action of medication_2:
163. Side effectsAdverse reactions_4:
164. Lab Values_4:
165. CONTRAINDICATIONS_4:
166. Nursing ImplicationsResponsibilities_2:
167. STUDENT NAME_6:
168. Medication 5:
169. Classification of Medication_5:
170. Trade Name_5:
171. Generic Name_5:
172. Dosage_5:
173. Dosage Forms_5:
174. Routes_5:
175. Why is THIS patient SPECIFICALLY receiving this medication_3:
176. Side effectsAdverse reactions_5:
177. Lab Values_5:
178. CONTRAINDICATIONS_5:
179. Nursing ImplicationsResponsibilitiesRow1_3:
180. 1:
181. 2:
182. 3:
183. Student Name:
184. Course Name: