NURSING PROCESS CAREPLAN STUDENT NAME: MEDICAL PREP INSTITUTE OF TAMPA BAY COURSE NAME: INSTRUCTOR: 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 Supporting Symptomatology: What patient data supports your selection Developmental Stage (Theory): Utilize Erikson. Identify Developmental Stage (Actual): Identify what developmental stage your primary problem and cause(s). what stage is applicable to your patient based on their age. Vital Signs/Frequency: of Pathophysiology? patient is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage. 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: Why is THIS patient SPECIFICALLY receiving this medication? Side effects/Adverse reactions: Lab Values: CONTRAINDICATIONS: Nursing Implications/Responsibilities: Routes: 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 Student Name: _____________________________________________ Category Excellent 1 Point GRADE: /9 Course Name: ______________________________________________ Good 0.75 Points Fair 0.50 Points Poor / Incomplete 0.25 Pts – 0 Pts Accurate and thorough Pt. demographic Patient Demographic Pg: Pt. Patient Demographic Page Patient Demographic Page is is incomplete, PATIENT DEMOGRAPHIC PAGE Primary Complaint, Medical is included, but missing one included, but missing several missing or Hx, Dx Proc, Surgical Proc., element. elements. inappropriate to Pathophys., Devel Stage, etc. patient. Contains adequate number Labs & Does not contain adequate Includes complete labs and of Labs/Diagnostics related Diagnostics number of Labs/ Diagnostics LABS & DIAGNOSTICS diagnostics sheet related to to & appropriate to portion is related to & appropriate to Includes labs and diagnostics appropriate to & appropriate to patient’s patient’s disease process, incomplete, patient’s disease process, and patient & patient’s disease process disease process: specific, & but labs & diagnostics may missing or may not be specific, labeled correctly labeled. not be specific or correctly inappropriate to or listed with rationales. labeled. patient. Assessment Includes all pertinent data Includes all pertinent data Does not include all pertinent ASSESSMENT portion is related to nursing diagnosis related to nursing data related to nursing Includes subjective, objective and historical incomplete, and does not include data diagnosis, but also includes diagnosis. May also include data that support actual or risk for nursing missing or that is not related to data not related to nursing data that does not relate to diagnosis. inappropriate to nursing diagnosis. diagnosis. nursing diagnosis. patient. DIAGNOSIS Diagnosis is appropriate for Diagnosis is appropriate for Diagnosis is not appropriate Diagnosis Includes the most appropriate diagnosis for patient and ordinal level, patient and ordinal level, for patient and ordinal level portion is patient and ordinal number that includes all and diagnosis is NANDA and diagnosis is NANDA (first diagnosis, second incomplete, appropriate parts (stem, related to or R/T, approved. Diagnosis also approved, but does not diagnosis, etc.). May also not missing or and as evidenced by AEB for actual includes all parts and include all parts or be NANDA and may not inappropriate to diagnosis) and is NANDA approved. information is listed in information is listed in include all parts. patient. (2 Physical & 1 Psychosocial) correct part of diagnosis. wrong part of diagnosis. PLANNING (Goal Setting) Goal statement is patient or Goal statement is patient or Goal statement is not patient Goal portion is Includes a patient or family goal that is most family oriented, and family oriented, and or family oriented and may incomplete, appropriate for the patient/family and the contains two measurable contains at least one not have measurable and/ or missing or nursing diagnosis. Goal should be realistic measurable and realistic realistic criteria or a target inappropriate to and measurable by at least two criteria and r
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