West Coast University:NURS 100 Nursing care plan example Latest Updated 2022/2023
Nursing Care Plan Student
... [Show More] Name
West Coast University Class Name
Term
Student
Instructor
Date
Course
Patient Initials
DOB / /
Unit/Room #
Height/Weight /
Allergies Code Status
Temperature
(C/F, Site) Pulse
(Site) Respirations Pulse Ox
(O2 %) Blood Pressure
(mmHg) Pain Scale
(010)
History of Present Illness Including Admission Diagnosis & Chief Complaint (normal & abnormal data) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
“Patient came in c/o pain on left side. Patient claims “tripped over cat” denies loss of consciousness.
Subjective Data Pain, Did not lose consciousness, midly incontenient, edema in ankles normal, difficulty urinating, tripped over cat, fell on left side.
Admission diagnoses left hip fracture.
& OBJECTIVE DATA bruise, 20G IV, edema, 3x3 bruising, no skin breakdown. Alert & oriented x4.
(Can put in full head to toe assessment)
Pertinent Lab Tests / Values (with normal ranges), Support with Evidence Based Citations
Lab Test Date Patient Result Normal Range Notes / Rationale
(Lab Tests: fingerstick 3/10/16 Result normal range 70105 Notes glu related to blood sugar, diabetes etc
Erikson’s Developmental Stage with Rationale Support with Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation &
Psychosocial Considerations/Concerns (3) Support with Evidence Based Citations
Erik Erikson’s development stages Socioeconomical Considerations:
Retired professor of nursing
Cultural Considerations:
African American
Spiritual Orientation:
Church every Sunday
Psychosocial Considerations:
Fear, anxiety, at risk for lonliness
(Think emotionally what they may experience or possible of feeling)
Potential Health Deviations, Predisposing & Related Factors (At least two) include three independent nursing interventions for each (“At
Risk for…” nursing diagnosis) Interprofessional Consults, Discharge Referrals, & Current Orders (Include diet, tests, and treatments) with Rationales supported with Evidence Based
Citations
POTENTIAL Problems** Not actual indicated problems. Will not get full credit.
Puls ox Npo
Priority Nursing Diagnosis
(at least 2)
Written in three part statement Planning (Outcome/Goal) Measurable goal during your shift (at least 1 per nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal) Rationale Each supported with
Evidence Based Citations
(1 per intervention) Evaluation Goal Met, Partially Met, or Not Met &
Explanation
Pain related to
evidenced by GOAL 4 interventions
(make sure to number 1 4 and match to rationale) Rationale for interventions Whether goal is met
Current Medications
Medications (with APA citations) Class/Purpose Route Frequency Dose & Range (if out of range, why?) Mechanism of Action Onset of
Action Common Side Effects Nursing Considerations (specific to pt)
List all Meds Ex. Nsaid with food
*** Considerations
To safely administer
medication**
You have to
know how the
drug acts and
the side effects
References
35 references required
NURISNG CARE PLAN RUBRIC
NAME: COURSE: DATE:
PATIENT INITIALS: PATIENT DISEASE/DISORDER:
Criteria 4
Exceeds Expectations 3
Meets Expectations 2
Approaching Expectations 10
Does Not Meet Expectations Score
History of Present Illness HPI explained in detail
with accurate and in depth understanding of HPI explained in some
detail with moderate understanding of chief HPI explained in limited
detail with marginal understanding of chief HPI details limited with
poor understanding of chief complaint and no X2
chief complaint and complaint or no support complaint and no support evidence based citations
supported by evidence from evidence based from evidence based to support
based citations citations citations
Physical
Assessment, & Identifies 56 key
assessment parameters Identifies 34 key
assessment parameters Identifies 12 key
assessment parameters Identifies assessment
parameters not relevant X2
Diagnostics tests/ relevant to medical relevant to medical relevant to medical to medical diagnoses,
procedures diagnoses with relevant diagnosis with relevant diagnosis, relevant relevant to diagnostic
diagnostic procedures diagnostic procedures diagnostic procedures procedures or not
supported by evidence supported by evidence and vaguely supported by supported by evidence
based citations based citations evidence based citations based citations
Past Medical &
Surgical History, Past medical/surgical
history detailed with full Past medical/surgical;
history given with partial Past medical/surgical
history given with No past medical/surgical
history given without X2
Pathophysiology explanation of
Pathophysiology for each explanation of identified
preexisting medical minimal explanation of
identified preexisting explanation; no pre
existing medical
diagnosis & accurate diagnoses & explanation medical diagnoses & few diagnosis identified or
details with specific accurate with some detail details related to the explanations inaccurate
detail related to the related to the client’s client’s history and and not related to the
client’s history and history and symptoms symptoms or not client’s history and
symptoms and supported
by evidence based supported by evidence
based citations supported by evidence
based citations symptoms with evidence
citations
Criteria 4
Exceeds Expectations 3
Meets Expectations 2
Approaching Expectations 10
Does Not Meet Expectations Score
Erikson’s Developmental Stages Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations Identifies and defines correct stage with examples of meeting/ not meeting tasks supported by evidence based citations Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations X2
Socioeconomic/ Psychosocial Assessment Describes socioeconomic and cultural background in complete detail with references, identifies 3 psychosocial concerns Describes socioeconomic and cultural background in some detail with references, Identifies 2 psychosocial concerns Describes socioeconomic and cultural background in vague detail without references, Identifies 1 psychosocial concern Describes socioeconomic and cultural background with no detail without references, Identifies no psychosocial concerns X1
Interprofessional Consults & Discharge Referrals Lists 3 or more appropriate collaborative issues/concerns Rationale demonstrates excellent understanding of consults and interventions Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory understanding of consults and interventions Lists 1 appropriate collaborative issue/concern Rationale demonstrates vague understanding of consults and interventions Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory understanding of consults and interventions X2
Potential Health Deviations Identifies TWO prioritized risk factors in proper format
Writes 3 independent nursing interventions Identifies 1 prioritized risk factor in proper format
Writes 2 independent nursing interventions Identifies 2 prioritized risk factors but not in proper format
Writes 1 independent
pertinent nursing intervention Does not identify prioritized risk factors Writes 01 independent nursing intervention not pertinent to the diagnosis X3
Criteria 4
Exceeds Expectations 3
Meets Expectations 2
Approaching Expectations 10
Does Not Meet Expectations Score
Priority Nursing Diagnosis TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support
diagnosis Written incorrectly with sufficient data to support diagnosis, not a priority Written incorrectly, not in correct format, or without sufficient data to support diagnosis X4
Planning/Goals & Evaluation Goal is measurable, realistic, related to the problem;
Data supports if goal is met, not met with appropriate revisions Goal is not measurable, realistic, related to the problem;
Data somewhat supports if goal is met, not met with appropriate
revisions Goal is not measurable, not realistic, related to the problem;
Data vaguely supports if goal is met, not met with inappropriate revisions Goal is not measurable, not realistic, not related to the problem;
Data does not support if goal is met, not met with inappropriate revisions X2
Implementation and Rationale Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using textbook or evidence based
citations Identifies 3 independent interventions with teaching; Scientific rational is supported with using textbook or evidence based citations Identifies 2 independent interventions with teaching; Scientific rational is vaguely relevant & not supported from textbook Identifies 1 independent intervention with teaching; Scientific rationale is not relevant & not supported from textbook X2
Medications Lists all MAR medications with relevant side effects
and nursing List all MAR medications but does not include relevant
side effects and nursing Lists most of the MAR medications with relevant side effects
and nursing List some MAR medications but does not include relevant
side effects and X2
considerations specific to patient and reasons why patient is
receiving drug considerations specific to patient and why patient is receiving
drug considerations specific to patient and why patient is receiving
drug nursing considerations specific to patient
General Organization Accurate APA format, Appropriate citations & references, No spelling or grammar errors 12 APA format errors, some citations, references are appropriate, minimal spelling or grammar
errors Many APA format errors, inappropriate citations or references, many spelling or grammar errors No APA formatting, no citation or references included, many spelling or grammar errors X1
TOTAL /100
Rev. 6. 15
COMMENTS:
FACULTY SIGNATURE: DATE: [Show Less]