Nursing Care Plan Example, Exams of Nursing

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Running head: NURSING CARE PLAN 1

West Coast University:NURS 100 Nursing care plan example

Latest Updated 2022/

Nursing Care Plan

Student Name

West Coast University

Class Name

Term

Xray  State what Xray is.  Citation. Then put YOUR patient’s results.

Relevant Diagnostic Procedures / Results Include dates and rationales supported with Evidence Based Citations

Pertinent Lab Tests / Values (with normal ranges), Support with Evidence Based Citations Lab Test Date Patient Result Normal Range Notes / Rationale

(Lab Tests: fingerstick  3/10/16  Result  normal range 70105  Notes glu related to blood sugar, diabetes etc

Erikson’s Developmental Stage with Rationale Support with Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) Support with Evidence Based Citations

Erik Erikson’s development stages

Socioeconomical Considerations:

Retired professor of nursing

Cultural Considerations:

African American

Spiritual Orientation:

Church every Sunday

Psychosocial Considerations:

Fear, anxiety, at risk for lonliness

(Think emotionally what they may experience or possible of

feeling)

RelatedDiagnostic to Label Contributing Factors As Evidenced by Signs and Symptoms

Potential Health Deviations, Predisposing & Related Factors (At least two) include three independent nursing interventions for each (“At Risk for…” nursing diagnosis) Interprofessional Consults, Discharge Referrals, & Current Orders (Include diet, tests, and treatments) with Rationales supported with Evidence Based Citations

POTENTIAL Problems** Not actual indicated problems. Will

not get full credit.

Puls ox

Npo

drug acts and

the side effects

References

35 references required

citations

Criteria 4

Exceeds Expectations

Meets Expectations

Approaching

Expectations

Does Not Meet

Expectations

Score

Erikson’s Developmental Stages Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations Identifies and defines correct stage with examples of meeting/ not meeting tasks supported by evidence based citations Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations

X

Socioeconomic/ Psychosocial Assessment Describes socioeconomic and cultural background in complete detail with references, identifies 3 psychosocial concerns Describes socioeconomic and cultural background in some detail with references, Identifies 2 psychosocial concerns Describes socioeconomic and cultural background in vague detail without references, Identifies 1 psychosocial concern Describes socioeconomic and cultural background with no detail without references, Identifies no psychosocial concerns

X

Interprofessional Consults & Discharge Referrals Lists 3 or more appropriate collaborative issues/concerns Rationale demonstrates excellent understanding of consults and interventions Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory understanding of consults and interventions Lists 1 appropriate collaborative issue/concern Rationale demonstrates vague understanding of consults and interventions Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory understanding of consults and interventions

X

Potential Health Deviations Identifies TWO prioritized risk factors in proper format Writes 3 independent nursing interventions Identifies 1 prioritized risk factor in proper format Writes 2 independent nursing interventions Identifies 2 prioritized risk factors but not in proper format Writes 1 independent pertinent nursing intervention Does not identify prioritized risk factors Writes 01 independent nursing intervention not pertinent to the diagnosis

X

Criteria 4

Exceeds Expectations

Meets Expectations

Approaching

Expectations

Does Not Meet

Expectations

Score

Priority Nursing Diagnosis TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis Written incorrectly with sufficient data to support diagnosis, not a priority Written incorrectly, not in correct format, or without sufficient data to support diagnosis

X

Planning/Goals & Evaluation Goal is measurable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions Goal is not measurable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions Goal is not measurable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions Goal is not measurable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions

X

Implementation and Rationale Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using textbook or evidence based citations Identifies 3 independent interventions with teaching; Scientific rational is supported with using textbook or evidence based citations Identifies 2 independent interventions with teaching; Scientific rational is vaguely relevant & not supported from textbook Identifies 1 independent intervention with teaching; Scientific rationale is not relevant & not supported from textbook

X

Medications Lists all MAR

medications with

relevant side effects

and nursing

List all MAR

medications but does

not include relevant

side effects and nursing

Lists most of the MAR

medications with

relevant side effects

and nursing

List some MAR

medications but does

not include relevant

side effects and

X