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SHELTON STATE COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
NURSING CARE PLAN/CLINICAL PATHWAYS
NUR 102
INSTRUCTION SHEET
FIRST PAGE
I.
Section One
A. Student name, Client (Patient) initials, room, age, date (the date you are
working on care plan), nursing care plan# ( !, 2, …), admission date – self
explanatory. Most of this data required in this section of the nursing care
plan will be found in the medical record.
B. Allergies – include medications, food, clothing, and latex (found in
medical record).
C. Advance Directive: DNR must be a written physician order. Check yes or
no if written in physician orders.
D. If a copy is in the medical chart –write yes to living will, if not check no.
E. List medical and surgical diagnoses as listed in the medical chart; note
those diagnoses that applies to this hospitalization or nursing home
admission.
II.
Present History:
A. Reason for admission (chief complaint – PQRST): Describe patient’s
chief complaint, not a medical or surgical diagnosis, by using P- what
provoked the sign or symptom and/or was a palliative measure, Qdescribe the or type or quality – throbbing, sharp, dull, etc, R – region or
location, whether it radiates or not; S – describe the severity or intensity of
the complaint; and T – timing – onset, duration, intermittent or if
continuous. Example: Sudden onset of severe intermittent pain in right
foot with no radiation. States pain is sharp and throbbing. Walking
causes pain to be worst. Analgesic medication and putting foot helps to
reduce pain.
B. Past History: Write about past illnesses, hospitalizations, accidents, drug
or alcohol abuse, nicotine use (smoking), surgeries.
C. Family History (Risk Factor): Describe the illnesses and diseases of family
members such as father had heart disease; if family member decease,
include in family history and state deceased. Example: Mother – cancer,
deceased.
D. Cultural/Psychosocial: Describe the ethnicity of client, family unit – such
as if married or single, who they live with, number of children, occupation
or place of employment. If retired, state so and give past occupation.
Example: Patient is African American housewife living with spouse and
three children ages 2, 6, 8 years in urban two story house. Patient has
never worked outside of home.
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E. Growth and Development (Erickson): According to Erickson, write the
client’s developmental stage using normal versus abnormal and state
which one is appropriate for client. Example: According to patient’s age,
patient is in ‘Ego Integrity vs Despair.’ Patient is in despair because she
refuses to eat and voices frustration and concerns about illness.
F. Patient/S.O. (significant other), perception of illness and discharge plan:
Describe if patient or S.O. is accepting of illness, pleasant, cooperative or
in denial, etc. Discharge plans include where the client is going,
estimated date of discharge, and whom will assist with care (caregiver). If
additional information or community resources are indicated with
discharge, indicate so. Example: Patient is confused and total care at
nursing home. No discharge plans. Spouse visits weekly and is accepting
of illness.
G. Educational Level/Learning Style: State the highest grade completed and
describe how the client’s learns. This is usually not found in the medical
record so you will have to ask the client. An example of the learning style
may be the client stating that they learn best with pictures, videos, written
materials, information repeated, demonstrating, etc. Example: Patient
completed high school. States he learns best with handouts and pictures.
H. Health Maintenance (preventive practice): Write the health measures
taken by the client to promote or maintain health – exercises, low fat,
mammograms, pap smears, prostate exams, etc. Example: Patient states
she has annual mammograms and pap smears. Denies exercising, proper
lo fat, lo calorie diet.
I. Diet: Write the name of the diet as ordered in the medical record. On a
5X8 card, give the following information about the client’s diet. Describe
what the patient can and can to consume on this diet. You may save and
use this card for other patients who share the same diet.
J. Appetite: % of diet consumed. This is found in chart or ask patient.
Example: Write 20% or 30% and state which meal – breakfast, 80%
lunch as found in chart on most recent clinical day.
K. Fluids (oral, enteral (tube) feedings in ml or cc’s for an eight or 24 hour
period): Use intake and output sheets located in medical record for this
information. Example: Past 24 hour report – I – 1500 cc, O – 1800 cc.
III.
Present Treatment
A. Therapeutic Modalities: Include consults such as respiratory, physical
therapy, dietician and treatments such as wound care, special diets or fluid
restrictions. May omit medications in this area. Medications will be listed
on another sheet. Example: Clean wound daily with normal saline, apply
dry sterile dressing and tape. Physical therapy twice a week.
B. Scheduled Diagnostic and Laboratory Work: Write if your client is
scheduled for daily laboratory work or radiology exam as ordered by
physician. Example: CBC daily or EKG in am.
C. Intravenous fluids/ Additive medication – rate cc/hr or gtt/hr. Give the
name, amount of IV fluid and the name and dose of medication within IV
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fluid. Patient may receive 1000cc IV fluid continuous and receive a small
infusion of 100cc containing medication intermittently. Example: D5W
1000cc every 8 hours and Ampicillin 500 mg IV in 100cc NS.
D. Laboratory Reports – self- explanatory; may add other lab reports.
Example: Write date of test, name of test, patient value (results) and
normal laboratory value.
E. Other Diagnostic Tests – self -explanatory; always report on most recent
test. If more than one test performed, laboratory or radiology, and results
are abnormal, indicate date and time of such. May use additional paper
for writing space. See example listed above in D.
SECOND PAGE
Primary Medical/Surgical Diagnoses: Use textbook or Taber’s Medical Dictionary to
define what the disease is and how it affects the body. Also know the signs and
symptoms, diagnostic tests use to diagnose disease process, treatment both medical and
surgical, and complications per textbook. Indicate appropriate nursing interventions per
disease process. May write information on large index cards for this area and reuse cards
for different patients with same diagnoses.
THIRD and FOURTH PAGE
On this page, you will perform your physical exam using I – inspection, P-palpation,
P-percussion, and A- auscultation. On this page, you have four columns. The first
column lists the body systems and the important areas to include in your exam. Your
exam should not be limited to just these areas but comprehensive as it pertains to your
client.
Second column – is the review of systems or subjective data. This column is divided into
two areas – comments from Day 1 Clinicals and for Day 2 Clinicals. Remember, we will
go to Clinical Settings either Monday and Wednesday (PN students) and Thursday and
Friday (RN students). Write what the patient states is a problem. Use the PQRST format
if patient states a complaint. If not complaint, indicate so. Example: Patient voices no
complaints. See example on page one for how to write chief complaint.
Columns three and four are for the IPPA physical exam. Review the Health Assessment
Handbook for detailed description and proper medical terminology for the physical
examination of each body system as listed on these pages.
FOURTH PAGE (CONTINUES)
In addition to the physical examination using the IPPA format, other areas are listed for
completion on this page and listed below:
Ability to perform ADL’s – describe activity level and client’s level of self-care. Are they
able to feed, dress, bath self? Do they have bathroom privileges? Example: Patient is
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total or complete care – requires bathing, feeding, dressing; unable to move extremities;
bed bound; incontinent of both urinary and bowel elimination. OOB with maximum
assistance once a day.
Fall Risk Assessment – describe the risk for injuries or falls by using the risk assessment
tool or questionnaire located in you Health Assessment Textbook.
Client Teaching Needs – Describe areas that require patient teaching to promote self care
and explain how come. Discuss your teaching strategies. Remember to include to whom
you are teaching, the teaching technique and how the client or caregiver responded.
Example: The patient was taught four symptoms and care of hyperglycemia. Patient was
instructed that weakness, fatigue, weight loss and hunger are signs and symptoms.
Treatment is to see the physician at once. Handouts with pictures and a video were used
in the teaching process. Patient responded by verbalizing three of the four symptoms and
the correct treatment.
What assessment data relates to this client’s diagnoses? Describe what you will assess
for as it pertains to the patient’s condition and disease process. Example: Vital signs
once a shift, I & O, auscultate heart and lungs, monitor peripheral pulses, skin integrity.
In care of chronically ill patients, you will probably list many things in this area.
List Nursing Diagnoses in order of Priority using Maslow’s Hierarchy of Basic Human
Needs (list at least six). For definition of Maslow Hierarchy Pyramid – see Potter and
Perry’s Basic Nursing Textbook. Example: Altered tissue perfusion related to diseased
lung, Altered comfort level due to dyspnea, Altered rest state due to weakness, etc.
FIFTH PAGE
Nursing Care Plan (see separate handout and Potter and Perry’s Basic Nursing Textbook
- Ch 6 Nursing Process)
SIXTH PAGE
Medication Information Sheet: Use Drug Textbook and look up information about drugs
as noted. Very important to include in this section nursing assessment and interventions
for administrating this medication. May use a 5X8 index card or purchase drug cards
with this information provided. If you use the drug cards, remember you will need to
write how come patient is taking this medication. Some drugs have more than one
purpose.
Client Medications: Self- explanatory . Include a statement to explain how come patient
is on this medication. In writing medications, provide complete information. Example:
Ampicillin 500 mg one tab every hours po.
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NURSING CARE PLAN
FIRST COLUMN
Assessment and Nursing Diagnosis
Write the Nursing Diagnosis: The Nursing Diagnosis has three parts; 1) NANDA is the
standardized name for the patient’s problem (use the exact NANDA wording); 2) related
to cause - write the cause for problem; 3) AEB ( as evidenced by) or AMB: (as
manifested by). You must not mention in this section any surgical or medical diagnoses,
because this is beyond your ability to change. Example: amputation above the Right
knee or Diabetes Mellitus. Do not use treatments as part of a nursing diagnosis. If
ordered by a physician, you can not change this order unless there is a complication and
the patient can not tolerate or refuses the treatment. Nursing diagnosis may represent an
actual problem or potential one.
Subjective Data: Patient, spouse, significant other or health care professional makes a
Statement regarding the problem.
Objective Data: All other data that is Observed. Physical exam findings, laboratory or
radiology, or other reports from the chart.
Note: Data in this column must be related to the one nursing diagnosis and should
support a problem or positive findings. Do not list any data that is normal findings or
fixed – meaning it can not be changed or improved, such as age, gender, race or CVA,
Cancer. This column should speak to an important patient problem, nursing diagnosis, in
which you the nurse can do something about it.
SECOND COLUMN
Planning – the next three columns are planning – 1. Patient Goals, 2. Nursing
Interventions and 3. Scientific Rationale
1. Patient Goals
Implementation Column
Implementation is the performance of nursing actions. Students write what was done and
the patient’s reponse. Direct nursing actions consist of independent or dependent nursing
action, collaboration or implementing protocols or standing orders. Example: SN
monitored vital signs. VS were stable and within normal range.
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Evaluation - Last Column
Evaluation is the measurement of client’s response to nursing actions and progress
toward achieving goals through the expected outcomes criteria (EOC). Write if goals met,
unmet or partially unmet. Discontinue care plan if goal met. Modify care plan if goals
are unmet or partially unmet. Continous process of assessing the patient. In this column
write a short explanation of why the student indicate goal met, unmet or partially unmet.
Example: Goal met – patient’s temperature was 99 F. EOC was temp would be 97-99 F.
Partially met – patient stated pain was ; Unmet – patient stated pain was at 6 on pain
scale of 0-10. EOC – patient would rate pain 0-4.
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