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.