Student Name:
Clinical Location/Ward: Date
Identify a patient you cared for in clinical. Use the information about selected patient to complete the care plan.
CARE PLAN #1
Care Plan for:
Medical Diagnosis
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Patient EMR
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Part 1: Nursing Process Model
| Nursing Assessment | |
| Subjective | |
| Objective | |
| Database | |
| Nursing Diagnosis (Priority Nursing Diagnosis and 1 Potential Diagnosis) NANDA | |
| Priority DX | |
| Potential | |
| Planning (SMART Goals)
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| Re: Priority | |
| Re: Potential | |
| Implementation – A. Independent Nursing Actions (Teaching) | |
| Activities | |
| Diet and Nutrition | |
| Prevention and Rehabilitation | |
| Implementation – B. Dependent Nursing Actions: Also state your Nursing Responsibilities | |
| Medications and Treatments
Include: Drug Classification, How is the drug taken, What are the side effects and adverse effects, what to do with the side effects or prevent them from happening |
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| Diagnostic Procedures
Include: What are your responsibilities as a Nurse, before, during and after the procedure
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| LAB Exams
Include: Why should be done, Normal Levels, What does an abnormal result indicate? |
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| Evaluation (Outcome of Activities): |
| Nursing Actions
Must include assessment, interventions, and patient teaching, accompanied by rationale for doing each. |
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| Action | Rationale |
Part 2: Clinical Judgement Model- Ref: Caputi (2019).
| Recognize Cues- NOTICING | |
| Signs and Symptoms
· Appearance · Behavior · Cognition · Thought processes |
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| Analyze Cues-INTERPRETING | |
| · Clustering of information
· Recognizing inconsistencies · Determining the importance of information · Distinguishing the relevant from irrelevant information · Judging how much ambiguity is acceptable · Comparing and contrasting
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| Prioritize Hypotheses | |
| · Setting Priorities | |
| Generate Solutions | |
| · PLAN nursing interventions
Ø Per disease process Ø Patient activities Ø Diet and Nutrition Ø Medication Ø Therapeutic procedures |
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| Take Action-RESPONDING | |
| · Delegating
· Communicating · Teaching · Implementation |
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| Evaluate Outcomes- REFLECTION | |
| · Effectiveness of:
Ø Accuracy of diagnosis Ø Interventions conducted Ø Medication Ø Procedures done |
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Reference page
On the following page, provide the APA style reference list used in preparing this care plan.
The instructor will check the sources and the APA style when grading your work.
References
Instructor’s Feedback
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Reviewed with Student: ________________________________ (Student Signature)
Faculty: ________________________________ (Faculty Signature)
Date: ________________________________
CARE PLAN GRADING RUBRIC
| CATEGORIES | Value | Earned | COMMENTS |
| Patient Information | |||
| Medical Diagnosis | 1 | ||
| Patient EMR | 4 | ||
| Part 1: Nursing Process Model | |||
| Subjective Data (Minimum of 3) | 5 | ||
| Objective Data (Minimum of 3) | 10 | ||
| Nursing Diagnosis: NANDA, Related To, AEB (Minimum of 2) | 10 | ||
| Goal: Condition, Time Frame, Parameters (Minimum of 3) | 10 | ||
| Assessment, Interventions, Patient Teaching, and Rationales for each (Minimum of 6) | 10 | ||
| Part 2: Clinical Judgement Model | |||
| Identify Client’s Needs (Minimum of 3) | 5 | ||
| Make Clinical Judgement (Minimum of 2) | 5 | ||
| Clinical Decisions (Minimum of 5) | 5 | ||
| Form a Hypothesis (Minimum of 1) | 5 | ||
| Generate Solutions (Minimum of 5) | 10 | ||
| Take Actions (Minimum of 5) | 10 | ||
| Evaluate Outcomes (Minimum of 2) | 5 | ||
| Reference Page | |||
| Cited all content used in the care plan | 2 | ||
| Citation followed the APA7th style formatting | 3 | ||
| Total | 100% |
The final grade reflects the percentage earned.
