West Coast University:NURS 100 Nursing care plan example Latest Updated 2022/2023,100% CORRECT

West Coast University:NURS 100 Nursing care plan example Latest Updated 2022/2023 Nursing Care Plan Student 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: