the nursing care plan format
TRANSCRIPT
The Nursing Care Plan Format
Thomas
Nursing Care Plan
•Formats:1. Standardized2. Concept or care mapping
Standardized Format
1. Format:a. Column for nursing diagnosesb. Column outcome / goalc. Column criteriad. Column nursing interventions with rationale
2. Negative aspects:a. Multiple pagesb. Hours to complete
RCACT Standardized Forms
• Completed care plan consists of:1. Assessment form2. System disorder (Pathophysiology sheet): one for
each current medical condition3. Medication (Diff sheet): one for each active
medication4. Care plan cover sheet: front and back5. Care plan additional sheet
Assessment
System Disorder (Pathophysiology Sheet)
Medication (Diff Sheet)
Care Plan Cover Sheet
Back of Cover Sheet
Additional Care Plan Sheet
Creating a Care PlanSIGNS/SYMPTOMS
56 YR. OLD FEMALESMOKES 2PK/DAY FOR 40 YEARS
C/O SHORTNESS OF BREATHHISTORY OF COPD
HOME OXGEN AT 2 L/M, NEB TX. Q-4 , CONGESTED NON-PRODUCTIVE , CHESTINFILTRATES RLL
COUGH, HR=132, RR=32, BP=165/98, TEMP=99 AXILLARY Spo2= 87% on room air
ACCESSORY MUSCLE USAGE.
Creating a Care PlanSIGNS/SYMPTOMS MEDICAL
DIAGNOSIS56 YR. OLD FEMALESMOKES 2PK/DAY FOR 40 YEARS
1. PNEUMONIA2. ACUTE
EXACERBATIONCOPD
C/O SHORTNESS OF BREATHHISTORY OF COPD
HOME OXGEN AT 2 L/M, NEB TX. Q-4 , CONGESTED NON-PRODUCTIVE , CHESTINFILTRATES RLL
COUGH, HR=132, RR=32, BP=165/98, TEMP=99 AXILLARY Spo2= 87% on room air
ACCESSORY MUSCLE USAGE.
Creating a Care PlanSIGNS/SYMPTOMS MEDICAL
DIAGNOSISNURSING
DIAGNOSIS56 YR. OLD FEMALESMOKES 2PK/DAY FOR 40 YEARS
1. PNEUMONIA2. ACUTE
EXACERBATIONCOPD
1. Impaired gas exchange r/t mucus in lungs AEB: Spo2 87% on room air
C/O SHORTNESS OF BREATHHISTORY OF COPD
HOME OXGEN AT 2 L/M, NEB TX. Q-4 , CONGESTED NON-PRODUCTIVE , CHESTINFILTRATES RLL
COUGH, HR=132, RR=32, BP=165/98, TEMP=99 AXILLARY Spo2= 87% on room air
ACCESSORY MUSCLE USAGE.
Creating a Care PlanSIGNS/SYMPTOMS MEDICAL
DIAGNOSISNURSING
DIAGNOSISMEASURABLE,
REALISTIC, TIMED GOAL
56 YR. OLD FEMALESMOKES 2PK/DAY FOR 40 YEARS
1. PNEUMONIA2. ACUTE
EXACERBATIONCOPD
1. Impaired gas exchange r/t mucus in lungs AEB: Spo2 87% on room air
Client will demonstrate Spo2 greater than 93% within 15 minutes.
C/O SHORTNESS OF BREATHHISTORY OF COPD
HOME OXGEN AT 2 L/M, NEB TX. Q-4 , CONGESTED NON-PRODUCTIVE , CHESTINFILTRATES RLL
COUGH, HR=132, RR=32, BP=165/98, TEMP=99 AXILLARY Spo2= 87% on room air
ACCESSORY MUSCLE USAGE.
Creating a Care PlanSIGNS/SYMPTOMS MEDICAL
DIAGNOSISNURSING
DIAGNOSISINTERVENTIONS MEASURABLE,
REALISTIC, TIMED GOAL
56 YR. OLD FEMALESMOKES 2PK/DAY FOR 40 YEARS
1. PNEUMONIA2. ACUTE
EXACERBATIONCOPD
1. Impaired gas exchange r/t mucus in lungs AEB: Spo2 87% on room air
Assess respiratory status R= baseline data.
Client will demonstrate Spo2 greater than 93% within 15 minutes.
C/O SHORTNESS OF BREATHHISTORY OF COPD
Administer 2 L/moxygen via NC as ordered per provider R=hypoxia
HOME OXGEN AT 2 L/M, NEB TX. Q-4 , CONGESTED NON-PRODUCTIVE , CHEST INFILTRATES RLL
Head of bed elevated greater than 30 degrees.
COUGH, HR=132, RR=32, BP=165/98, TEMP=99 AXILLARY Spo2= 87% on room air
Administer 125mg IV Solumedrol R+ inflammation
ACCESSORY MUSCLE USAGE.
Administer nebulizer unit dose xopenes PO
What is Concept Mapping• Concept mapping:
1. Also called care mapping2. Method of organizing information in graphic or pictorial form.3. Identify a main subject with interconnected links to related
components.• Positive Strategies:
1. Promotes critical thinking2. Select significant information3. Organize related concepts on a one or two page working
document.4. Select a map format using circles or boxes and draw lines or
arrows linking relationship within the map.
Spider: organized around a central theme at the middle of the map with lines to subtopics
Hierarchical: shows information in descending fashion, general to specific, with lines and arrows depicting relationships
System: provides a concept and links components, showing their interrelationships
Components Within a Concept Map
• Client's reasons for seeking health care• Focus assessments• Nursing diagnoses• Expected outcomes• Nursing interventions• Evaluation of client's response
Positive Feedback from Users of Concept Mapping
• Allows student to integrate previous knowledge with newly acquired information• Enable students to organize and visualize relationships between their
current academic learning and new, unique client assignments.• Increases critical and clinical reasoning skills• Enhance retention of knowledge• Correlated theoretical knowledge with nursing practice• Helps students recognize information that they must review or lean to
promote safe, appropriate client care• Promotes better time management for beginning students otherwise
focused on the composition requirements of nursing care plans rather than use of the nursing process itself
Creating a Care Plan Concept Map
DEMOGRAPHICS
Creating a Care Plan Concept Map
DEMOGRAPHICS
NX. DX.
NX. DX.
NX. DX.
NX. DX.
Creating a Care Plan Concept Map
DEMOGRAPHICS
NX. DX.
NX. DX.
NX. DX.
NX. DX.
INTERV
INTERV.
INTVER
INTERV
INTERV
INVTER
INTERV
INTERV
Creating a Care Plan Concept Map
DEMOGRAPHICS
NX. DX. 2
NX. DX. 4
NX. DX. 1
NX. DX. 3
INTERV.
INTERV
INTERVINTERV
INTERV INTERV
INTERVINTERV
GOAL
GOAL
GOAL
GOAL
Instructions for Care Plan• Completed care plan to be submitted in your clinical instructors box located in the lab in
a folder the following Monday morning post clinical at 8:00 am unless instructed otherwise.
• Basic Skills Phase: 1 care plan• Medsurg Phase: 3 care plans• Specialty Phase: 3 total, one care plan for each rotation; special forms will be given by
instructors.• Student will not progress until each care plan is checked off by the clinical instructor.• ACT Standardized Care Plan to be submitted will consist of:
1. 10 - NANDA-I nursing diagnoses2. 10 - interventions for one diagnosis; total 1003. All interventions will have a rationale written with it; total 1004. One measurable, realistic, timed goal for each nursing diagnosis; total 105. Medication list on notebook paper with dosage, route, and frequency.6. Assessment
• Medication and pathology sheets will be hand written.• Write legible; if the care plan isn’t legible it will be returned to the student and the
student will be assigned a new care plan to complete.
Summary• Completed care plan consists of:
1. Assessment form2. System disorder (Pathophysiology sheet): one for each current
medical condition3. Medication (Diff sheet): one for each active medication4. Care plan cover sheet: front and back5. Care plan additional sheet
• Concept mapping:1. Also called care mapping2. Method of organizing information in graphic or pictorial form.3. Identify a main subject with interconnected links to related
components.• Completed care plan to be submitted in your clinical instructors box
located in the lab in a folder the following Monday morning post clinical at 8:00 am unless instructed otherwise.