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 Patient Demographic Pg: Pt. Patient Demographic Page PATIENT DEMOGRAPHIC PAGE Primary Complaint, Medical is included, but missing one element. Hx, Dx Proc, Surgical Proc., Pathophys., Devel Stage, etc. Contains adequate number Includes complete labs and of Labs/Diagnostics related diagnostics sheet related to to & appropriate to LABS & DIAGNOSTICS Includes labs and diagnostics appropriate to & appropriate to patient’s patient’s disease process, disease process: specific, & but labs & diagnostics may patient & patient’s disease process correctly labeled. not be specific or correctly labeled. Includes all pertinent data ASSESSMENT related to nursing diagnosis Includes subjective, objective and historical and does not include data data that support actual or risk for nursing that is not related to diagnosis. nursing diagnosis. DIAGNOSIS Diagnosis is appropriate for Includes the most appropriate diagnosis for patient and ordinal level, patient and ordinal number that includes all and diagnosis is NANDA appropriate parts (stem, related to or R/T, approved. Diagnosis also and as evidenced by AEB for actual includes all parts and diagnosis) and is NANDA approved. information is listed in (2 Physical & 1 Psychosocial) correct part of diagnosis. PLANNING (Goal Setting) Goal statement is patient or Includes a patient or family goal that is most family oriented, and appropriate for the patient/family and the contains two measurable nursing diagnosis. Goal should be realistic and measurable by at least two criteria and realistic criteria and a target date or time. and have a target date or time. Interventions portion contains adequate number IMPLEMENTATION (Interventions) of interventions to help Includes 3 interventions or nursing actions patient/family meet goal, that directly relate to the patient’s goal, that and interventions are are specific in action and frequency, consist specific in action and of 1 monitoring, 1 action and 1 teaching frequency, consist of 1 intervention. Interventions should be monitoring, 1 action and 1 appropriate to help patient or family meet teaching intervention and their goal. are listed with appropriate rationales. Evaluation portion does EVALUATION contain data that is listed as Includes data that is listed as criteria in goal criteria in goal statement. statement. Based on this data, goal is Does describe goal as met, determined to be met, partially met, or not partially met, or not met. If met. If goal was not met or partially met, goal was partially met or plan of care is revised or continued and a not met, includes revision new evaluation date/time is set. and/or new evaluation date/time. Includes 5 or more drug DRUG CARDS cards related to and Includes at least 5 drug cards appropriate appropriate to patient’s to patient, complete and accurately selected. disease process. Pt. demographic Patient Demographic Page is is incomplete, included, but missing several missing or elements. inappropriate to patient. Labs & Does not contain adequate Diagnostics number of Labs/ Diagnostics portion is related to & appropriate to incomplete, patient’s disease process, and missing or may not be specific, labeled inappropriate to or listed with rationales. patient. Assessment Includes all pertinent data Does not include all pertinent portion is related to nursing data related to nursing incomplete, diagnosis, but also includes diagnosis. May also include missing or data not related to nursing data that does not relate to inappropriate to diagnosis. nursing diagnosis. patient. Diagnosis is appropriate for Diagnosis is not appropriate Diagnosis patient and ordinal level, for patient and ordinal level portion is and diagnosis is NANDA (first diagnosis, second incomplete, approved, but does not diagnosis, etc.). May also not missing or include all parts or be NANDA and may not inappropriate to information is listed in include all parts. patient. wrong part of diagnosis. Goal statement is patient or Goal statement is not patient Goal portion is family oriented, and or family oriented and may incomplete, contains at least one not have measurable and/ or missing or measurable and realistic realistic criteria or a target inappropriate to criteria or a target date or time. patient. date/time. Interventions portion Interventions portion does Interventions contains adequate number not include adequate number portion is of interventions to help of interventions to help incomplete, patient/family meet goal, patient/family meet goal. missing or but interventions may not Interventions may also not inappropriate to be specific, labeled or listed be specific, labeled or listed patient. with appropriate rationales. with appropriate rationales. Evaluation portion does contain data that is listed as criteria in goal statement, but does not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time. Evaluation portion does not contain data that is listed as Evaluations criteria in goal statement. portion is May also not describe goal as incomplete, met, partially met, or not missing or met. May also not include inappropriate to patient. revision or new evaluation date/time. Includes at least 4 drug Includes at least 3 drug cards Drug Cards are cards related to patient’s related to patient’s disease incomplete or disease process. process. missing. Additional Criteria: (Total 1 point) ⃝ Paper is Typed. ⃝ Spelling Correct. ⃝ Neat. ⃝ At least 3 References in proper APA Format. A 48 year old male is admitted to the interventional holding area after having a cardiac cath. The patient received a cardiac stent in the right coronary artery (RCA) and the insertion site was angiosealed. The insertion site is soft, no bruising noted, or active bleeding. Pulses are palpable in bilateral lower extremities. A sandbag in on the site which has to stay for another 1.5 hours per md orders. The patient is complaining of discomfort in the groin area and rates his pain 8 on 1-10 scale. In addition, the patient and his wife have verbalized they desire (but feel they will not be able to) to manage the new medication regime and post-op care and are having difficulty understanding why it is so important to take these new medications and quit smoking since he already “has his problem fixed with the stent placement”. He states he is going to have problems integrating these new “rules” into his daily life because he works around people who smoke all the time and does not want these medications to interfere with his life.interventional holding area after having a cardiac cath. The patient received a cardiac stent in the right coronary artery (RCA) and the insertion site was angiosealed. The insertion site is soft, no bruising noted, or active bleeding. Pulses are palpable in bilateral lower extremities. A sandbag in on the site which has to stay for another 1.5 hours per md orders. The patient is complaining of discomfort in the groin area and rates his pain 8 on 1-10 scale. In addition, the patient and his wife have verbalized they desire (but feel they will not be able to) to manage the new medication regime and post-op care and are having difficulty understanding why it is so important to take these new medications and quit smoking since he already “has his problem fixed with the stent placement”. He states he is going to have problems integrating these new “rules” into his daily life because he works around people who smoke all the time and does not want these medications to interfere with his life. Nursing Diagnosis: -Acute Pain related to tissue trauma and prescribed post procedureimmobilization as evidence by patient rating pain 8 on 1-10 scale. Demographics: White male, 48 years old. Weight is 285 pounds, Height is 5’9″. Pt is married and his wife and 2 children are at the bedside. Pt speaks fluent English. He is Catholic. He finished high school and 2 years of community college. He is employed in an office with about 30 other employees. Past medical history: HTN, Hyperlipidemia, Smokes Current labs: Glucose – 165, Sodium 140, Potassium 3.2, Chloride 98, BUN 15, Creatinine 0.8. Chest Xray – normal Medications: Select 3 medications for your care plan. One should be for hypertenstion, 1 should be for pain while in the hospital, the 3rd one is of your choice (a medication that goes along with his diagnosis). Nursing Outcomes: -The patient will rate his groin pain less than 5 on a 1-10 scale within in 2 hours from admission. -The patient and his wife will relate to the nurse that they feel like they can integrate the new medication and stop smoking regimen into their lifestyle before discharge. -The patient and his wife will verbalize 4 benefits of quitting smoking for the heart by discharge. -The patient and his wife will demonstrate and verbalize how to administer and take his new medications before discharge. Nursing Interventions: -The nurse will assist the patient with re-positioning techniques as needed to help alleviate pain. -The nurse will educate the patient and his wife on 4 benefits of quitting smoking by discharge. -The nurse will verbalized and demonstrate to the patient and his wife how the patient needs to take his new medications by discharge. The patient and his wife will verbalize their understanding of the medications.
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