Nursing care plan

· 3 Nursing diagnoses in priority from highest to lowest

· The highest priority nursing diagnosis is required to be broken down for the care plan.

· The highest priority nursing diagnosis should include:

· 3 interventions

· 3 goals

· 2 short-term

· 1 long-term

· Evaluation of Goals/Outcomes

· 2 met goals

· 1 unmet goal

· Stimuli

· 1-focal

· 1-conceptual/contextual

· 1-residual

· Subjective

· 2-3 verbal statements

· Objective

· 3-4 observable

· Teaching and Discharge Needs Related to Behaviors and Stimuli

· Please include all the teaching to help the patient transition from a facility, hospital, or even agency back to home. The point of teaching and discharge needs are to prevent patients from being re-hospitalized for the same issues. Think “disease management and preventing exacerbation”.

· Include: referrals for medical social worker, physical therapy, occupational therapy Etc.…if you think the patient will need additional rehab assistance while at home to become more stable.

· The first page of the care plan document is mainly data collection (assessment).

· On the second page you have a psychosocial section.

· Self-concept

· You must include any of the three: body image/religion/Erikson’s stages (Exp. Erikson’s stages are located in your Fundamentals book). At least one of the items has to be addressed.

· Role function

· What role did the patient most likely will need to transition to after diagnosis or impairment. (Exp. If the patient had a right lower leg amputation and his full-time job was a roofer. What adaptations will be needed for him to eventually function in day-to-day life such as: physical therapy, prosthetic, and/or infection management?

· Interdependence

· What are the patient’s support systems

· Community, family, spouse, job Etc.…

· Stimuli ( Review pages 5-6 of the Application of Roy’s Adaptation Modal {RAM} to get examples of what are needed for each of these categories). This paper was handed out on the first day of class.

· Focal

· Conceptual/contextual

· Residual

· Medications

· Name, dose, frequency, route, and nursing considerations (must be included).

· Laboratory and Diagnostic Studies.

· List abnormal values only.

· Teaching and Discharge Needs Related to Behaviors and Stimuli (examples given on page 1).

· On the third page focal, conceptual/contextual, and residual stimuli is mentioned again.

· Use the same information you entered on the second page for focal, conceptual/contextual and residual.

· This page should list your three priority diagnoses and break down the highest priority one.

· REMEMBER:

Enter all of the medications

· Do not forget the nursing considerations for each medication.

· Enter all of the abnormal labs or diagnostic test only used on the patient in the case study.

· Please make sure your name, instructor name, site name, and date are on all of the forms.

· If you do not have the information from the case study or additional information page on the patient to enter in the data collection portion on page 1. Please place an N/A in the space. There should be no blank areas on the care plan.