How to Write a Nursing Care Plan

Nursing Care Plan and Diagnosis for Chronic Pain Nursing Care Plan and Diagnosis for Chronic Pain This nursing care plan is designed for patients with chronic discomfort. According to Nanda, chronic pain is the condition in which an individual experiences persistent or intermittent pain that lasts for more than six months. This definition differs from that of acute pain, in which a person experiences agony from one second to six months. The patient may report typical symptoms of distress, but they have persisted for at least six months. Due to the patient experiencing these symptoms for more than six months, the nurse may observe social and familial relationship disruption, irritability, depression, a \"beaten\" appearance, exhaustion, or somatic preoccupation. There are numerous causes of chronic pain, including musculoskeletal disorders such as back pain, treatment-related therapies such as chemotherapy, and pregnancy. This nursing care plan for chronic back pain includes a nursing diagnosis, nursing interventions, and nursing objectives. What are intentions for geriatric care? How is a nursing care plan developed? Which nursing care plan literature would you recommend to assist in the creation of a nursing care plan? Care Plans are frequently developed in various formats. The format is not always crucial, and the format of care plans may vary between nursing institutions and medical employment. Some hospitals may display the information digitally or utilize pre-made templates. The most essential aspect of the care plan is its content, as it will serve as the basis for your care. Nursing Care Plan for Chronic Pain Please observe the video below for a tutorial on how to construct a care plan in nursing school. Otherwise, please continue down to view the finished care plan. Scenario A 56-year-old male presents with complaints of back discomfort. He states that he has experienced consistent lower back pain for the past year. He explains that he decided to come in to have it \"checked out\" because it is \"taking a toll\" on his ability to function. He reports that the back pain has left him despondent and exhausted because he cannot perform the same tasks he did a year ago. He also reports that his relationship with his wife and children has been affected. You observe that the patient appears fatigued with dark circles under his eyes and is frequently rubbing his back.

Nursing Diagnosis Inflammation of the lumbar spine is the cause of the patient's one-year history of consistent lower back pain, disruption of social and familial relationships, depression, fatigue, a \"beaten look,\" and rubbing of the painful area. Subjective Data He states that he has experienced consistent lower back pain for the past year. He explains that he decided to come in to have it \"checked out\" because it is \"taking a toll\" on his ability to function. He reports that the back pain has left him despondent and exhausted because he cannot perform the same tasks he did a year ago. He also reports that his relationship with his wife and children has been affected. Objective Data A 56-year-old male presents with complaints of back discomfort. You observe that the patient appears fatigued with dark circles under his eyes and is frequently rubbing his back. Nursing Outcomes -At the next follow-up appointment, the patient will report an improvement in back pain and an increase in daily activities. -The patient will verbalize his expectations regarding the course of pain treatment and his intended treatment outcomes and objectives. -The patient will identify five noninvasive pain relief methods to aid in pain management. -The patient will be instructed verbally on how to take the back pain medication prescribed for him as needed. Nursing Interventions At the next follow-up appointment, the nurse will evaluate the patient's report of reduced back pain and an increase in daily activities. -The nurse will evaluate the patient's expectations regarding the duration of pain treatment and his desired treatment outcomes. -The nurse will educate the patient on five noninvasive pain relief techniques to aid in pain management. -The nurse will instruct the patient on how to take the back pain medication prescribed for him as needed.

SAMPLE Block format Soap Note PATIENT INFORMATION Name: Mr. W.S. Age: 65-year-old Sex: Male Source: Patient Allergies: None Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. SUBJECTIVE: Chief complain: “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Respiratory: Patient denies shortness of breath, cough or hemoptysis. Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10. General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec. Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation. Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness. Integumentary: intact, no lesions or rashes, no cyanosis or jaundice. Assessment Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed. Differential diagnosis: Ø Renal artery stenosis (ICD10 I70.1) Ø Chronic kidney disease (ICD10 I12.9) Ø Hyperthyroidism (ICD10 E05.90) Plan Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease. These basic laboratory tests are: · CMP · Complete blood count · Lipid profile · Thyroid-stimulating hormone

· Urinalysis · Electrocardiogram Ø Pharmacological treatment: The treatment of choice in this case would be: Thiazide-like diuretic and/or a CCB · Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Ø Non-Pharmacologic treatment: · Weight loss · Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat · Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults · Enhanced intake of dietary potassium · Regular physical activity (Aerobic): 90–150 min/wk · Tobacco cessation · Measures to release stress and effective coping mechanisms. Education · Provide with nutrition/dietary information. · Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP · Instruction about medication intake compliance. · Education of possible complications such as stroke, heart attack, and other problems. · Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn. · No referrals needed at this time. References Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series). Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0 Patient Assessment and Care Plan Instructions to student: 1) Bring one copy of this packet with you to clinical each week. 2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet. 3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect. 4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly. PATIENT ASSESSMENT FORM STUDENT NAME: DATE: CLIENT INITIALS: ROOM # DOB: AGE GENDE ADMISSIO CODE STATUS: R: N DATE: MEDICAL DX: ALLERGIES: MARITAL OCCUPATIO STATUS: N (FORMER): CHIEF COMPLAINT :

PAST HISTORY RATIONAL (SURGERY/PROCEDUR E (Why is ES) WITH DATES this ordered for this ORDERS client???) EXAMPLE: DIET 2 g Sodium Sodium is diet with restricted due nectar thick to edema in liquids only the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke. DIET ACTIVITY I/O VS BGM FOLEY NG PEG/PEJ TUBE WOUND CARE RESPIRATORY TREATMENT TRACHEOSTOMY SUCTIONING CHEST TUBE SPECIAL EQUIPMENT LAB ORDERS OTHER REHAB SERVICES ACTIVITY RATIONAL OR E

TREATMEN T PLAN & SCHEDULE PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY ....../ 5 pts IVs SITE LOCATION AND CONDITION: LAST TUBING CHANGE: IV FLUID AND RATE: REASON FOR IV ACCESS: LAST DRESSING CHANGE: GAUGE: DIAGNOSTIC DATE RESULTS REASON FOR TESTING AND CARE TESTS: IMPLICATIONS FOR NURSING LAB NORMS IMPLICATIONS FOR NURSING CARE TEST DATE RESULTS REFERENCE (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP RANGES IMPROVE AN ABNORMAL RESULT?)

GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development) TASKS OF THIS STAGE: CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO HAVIGHUSRT ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF TASKS ...../ 5 pts MEDICATIONS If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below. Brand Name and Generic Name Normal Dosage Ranges Contraindications Asthma, heart block Coreg (carvedilol) 3.125 mg – 50 mg BID Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions β-adrenergic blocker 6.25 mg p.o. BID Bradycardia, CHF, Why this Patient Receives this thrombocytopenia, Med hyperglycemia, bronchospasm Effects of the Med on the Nursing Considerations and Client Teaching

Do not discontinue abruptly or BP’s for past 3 days have before surgery been 128/78, 132/72, 138/80 Caution with Upper airway dysfunction He has a history of hypertension but has been taking Coreg for 2 years to control his hypertension Rise slowly to minimize orthostatic hypotension, check How is this medication B/P and heart rate prior to administration impacting your client??B/P readings, lab results, pain management, etc…….. Take before meals #1 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route & Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #2 Brand Name and Generic Normal Dosage Ranges Contraindications Name #3 Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #4 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #5 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching

# 6 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #7 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #8 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #9 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #10 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching

#11 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching #12 Brand Name and Generic Normal Dosage Ranges Contraindications Name Pharmacotherapeutic Class Dosage, Route and Adverse Reactions Frequency Why this Patient Receives this Effects of the Med on the Nursing Considerations and Med Client Teaching ...../ 20 pts NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments. We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long resident follows below. TEMP: APICAL HR: RESP: BP: HT: WT: (TYPE HERE) DATE / TIME Sample Narrative Note --- Head to Toe format Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145 Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without erythema or exudate. No chewing or swallowing difficulties. 75% of general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic 12/22/2010 turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal. 1400 Motor and sensory functions grossly intact. No weakness or paralysis. Upper extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion. Apical pulse regular (rate) and rhythm. Double lumen picc line note to left antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active

x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this morning, passed a large, soft- formed brown stool and a moderate amount of clear yellow urine. Bilateral lower extremities, no tenderness, swelling or joint deformities noted. Denies numbness or tingling to extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses palpable and equal bilaterally. PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down your assessment findings.) ROUTINE FINDINGS PATIENT VARIATIONS/ABNORMALS COGNITION/NEUROLOGICAL (SAMPLE) (SAMPLE) “Fine resting tremor of left hand Alert and oriented x3, recent and remote memory intact. Denies any numbness or tingling to extremities” SKIN SENSORY Wound measurements and complete BREASTS - description if available at the very least RESPIRATORY – Document dressing including the type of dressing and description of condition! DEFERRED. (Include ventilator settings as indicated in narrative note) Include any vascular access device, IV lines, AV fistulas, perma -cath lines, etc. CARDIOVASCULAR ABDOMEN – Include any enteral feedings here and route . BOWEL CONTINENCE? LAST BM? BOWEL PLAN?

MUSCULOSKELETAL - URINARY CONTINENCE? TOILETING GENITOURINARY - PLAN? DEFERRED. PELVIC - RECTAL - DEFERRED. ....../ 10 pts NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at least 10) and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be priority 1, 2, or 3!!!!! Expectation is to have at least 10 nursing diagnosis listed! # List the Client An appropriate Related to part of the As evidenced by part of the problem Nursing Diagnosis statement (This is statement (This is stem individual to your individual to your client) SAMPLE: client) (REFER TO YOUR REMEMEBR THIS IS 1 Reports severe NURSING “related to” fractured NOT USED IN A “Risk pain in the right DIAGNOSIS LIST) right hip For” diagnosis “Acute Pain” “related to “ “as evidenced by” verbal immobility report of pain rated at an 8 hip. on a scale of 0 –to 10. 2 SAMPLE: rest “Risk for Impaired NONE it is a “Risk for” Complete bed skin integrity” diagnosis so there is no evidence statement

From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map. SAMPLE NCP NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal report of pain rated 8 on a scale of 0 -10. OUTCOME ASSESSMEN STATEMEN INTERVENTIONS SCIENTIFIC EVALUATIO T T RATIONALE N OF (Individualized, OUTCOME specific, frequency) (Data that (Patient (Supporting statement directly centered, from text or other (Met, partially pertains to the realistic, Minimum of 4-5 source, cite source) met, unmet, above nursing specific, interventions per plan unknown by diagnosis) measurable, target time) target time) 1. Educate the client on 1. “There are many Short Term the importance of pain ways to manage pain. In Goal: Met; relief to enhance her addition to pain was rated SHORT rehabilitation efforts pharmacologic and non- at a 2 on a TERM: SUBJECTIVE Client will and include education pharmacologic scale of 0 to 10 DATA: “My report pain level rated at on various types of measures, simple after right hip hurts a 3 or lower 30 minutes methods to relieve pain. nursing interventions administration me so much after pain can alter patients’ pain of Vicodin. medication every time I taken experience and speed their recovery.” Taylor, move. I am so Lillis and White pg. afraid to start 1168. physical therapy” 2. Encourage client to express any questions or concerns she may have regarding pain 2. “Common fears management methods include a loss of control

to alleviate anxiety and and embarrassment by fears. being unable to deal with pain maturely… Long Term The patient may view Goal. In the need of for progress medication as a sign of weakness or may fear addiction or loss of effectiveness at a later 3. Educate the client on date.” Taylor, Lillis and her responsibility to White pg. 1169. honestly report pain when it occurs as well as reporting if the current pain management is effective or ineffective 3. “As a patient for providing her pain advocate, ensure that a relief strong emphasis on the need for aggressive, individualized strategies that can minimize or 4. Provide for eliminate acute pain and alternative/complement improve patient ary measures of pain outcomes. Preventing relief, such as, reduce pain is easier then lighting and noise, treating it once after it soothing music, pet occurs.” Taylor, Lillis therapy, massage, and and White pg. 1178. hot/cold packs according to client preferences. 4. Alternative/complement ary measures will provide an added benefit of distraction from pain experience and augment analgesic effect. Cold/hot therapy can provide constriction and or dilation which will reduce pain inflammation in each specific circumstance Daniels. Pg 378

OBJECTIVE DATA: Alert and oriented 70 year old widowed female. Lives in an apartment independently. 2 daughter live nearby and visit often. History of a fall while out shopping 1 ½ LONG weeks ago. TERM: Right hip Client will surgically report pain repaired 7 level of 2 or days ago. less using Surgical ibuprofen dressing to with right hip is alternative clean, dry and pain control intact. methods by Circulation, discharge. motion and sensation intact to right lower extremity. Afebrile; BP 124/80; R-18 AP 84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears eye glasses

Medical history positive for osteoarthritis and osteoporosis Non weight bearing to right leg and to use a walker for ambulation To start physical therapy for gait and strength training BID times 7 days and occupational therapy to develop upper body strength once daily times 7 days Reports pain level is at 8 on a scale of 0 to 10. Has Vicodin 5mg/325 mg po 2 tabs every 4 hours prn for severe pain Ibuprofen 400 mg every 6 hours prn for moderate pain.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: SCIENTIFIC ASSESSMENT OUTCOME RATIONALE EVALUATION STATEMENT INTERVENTIONS (Supporting OF OUTCOME (Data that directly (Patient centered, (Individualized, statement from (Met, partially pertains to the realistic, specific, specific, frequency) text or other met, unmet, above nursing measurable, source, cite unknown by diagnosis) target time) source) target time) SUBJECTIVE SHORT TERM: DATA: LONG TERM: OBJECTIVE DATA: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) ...../30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: SCIENTIFIC ASSESSMENT OUTCOME RATIONALE EVALUATION STATEMENT INTERVENTIONS (Supporting OF OUTCOME (Data that directly (Patient centered, (Individualized, statement from (Met, partially pertains to the realistic, specific, specific, frequency) text or other met, unmet, above nursing measurable, source, cite unknown by diagnosis) target time) source) target time) SUBJECTIVE SHORT TERM: DATA: LONG TERM: OBJECTIVE DATA: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) ..../30 NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: ASSESSMENT OUTCOME INTERVENTIONS SCIENTIFIC EVALUATION (Data that directly STATEMENT OF OUTCOME pertains to the (Individualized, RATIONALE specific, frequency)

above nursing (Patient centered, (Supporting (Met, partially diagnosis) realistic, specific, statement from met, unmet, measurable, text or other unknown by target time) source, cite target time) source) SUBJECTIVE SHORT TERM: DATA: LONG TERM: OBJECTIVE DATA: Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks. Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) ................/30 Key Problem: Impaired urinary elimination Data: Intake=3800 Output=3200 Polyuria 3+ glucose in urine AEB: Polydipsia and polyuria Outcomes: Pt. will have urine output of 1000 – 2000 ml/24 hours. Interventions:

Monitor I & O q shift. Monitor BGM a.c. and h.s. Monitor kidney function tests Administer antihyperglycemics as ordered. Key Problem: Knowledge deficit Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine AEB: Verbal statements and questions. Outcomes: Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique by discharge. Interventions: Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style. Provide information q shift according to teaching plan recorded in EMR and document pt’s response. Reassess level of knowledge daily. Provide written information. Provide educational resources available in the community. Medical Problems (Pathophysiology)/Surgical Procedures: Newly diagnosed diabetic Key Assessments: S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals Tests: FBS, hemoglobin A1C “I don’t know how this fits”

Recent widow Kids live out of state ? support system Key Problem: Acute anxiety Data: Restless, verbally states she is anxious. AEB: Pt states “I don’t know what I will do with diabetes, this is too much.” Outcomes: Pt. will verbalize under-standing of resources available by discharge. Interventions: Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions. Demonstrate progressive relaxation exercises and have pt. return demonstrate. Provide pt. with a list of community resources for newly diagnosed diabetics. Identify client’s perception of anxiety Utilize empathy. Past Medical History: Hypertension x 20 years; appendectomy at age 9. Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary lifestyle; 290 pounds, age 52 Key Problem: Imbalanced nutrition, more than Data: BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs AEB: Anthropometric measurements. Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior to discharge. Interventions:

Assess client’s knowledge of nutrition and its relationship to diabetes. Arrange for dietary consultation. Reinforce teaching by dietician. Encourage physical activity as a weight loss strategy. Provide pt with community resources that can assist her with weight loss goal. “I DON’T KNOW HOW THIS FITS” PAST MEDICAL HISTORY RISK FACTORS MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES: KEY ASSESSMENTS: Key Assessments: Tests: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS:

KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: RUBRIC for Grading Packets /60pts KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: KEY PROBLEM: DATA: AEB: OUTCOMES: INTERVENTIONS: Student Name: Clinical Date: Site: Section Grading Criteria Satisfactory Or Comments, Unsatisfactory Kudos, Things to Improve for Next Time

10 points Page 1 fully and correctly completed 5 pts _/5___ _/5___ Patient Demographics, /2 Page 2 fully and correctly Diagnoses, Surgeries, completed 5 pts Orders, Rehab, IV, Imaging and Lab Medication Trade Name 2 pts Medication Generic Name 2 pts / 2 Pharmacological Classification 2 / 2 pts /2 20 points Normal Dosage Range 2 pts Medications /2 Dose ordered 2 pts /2 Route and Frequency 2 pts /2 Contraindications 2 pts /2 Adverse Effects/Reactions 2 pts /2 Nursing Considerations & Teaching 2 pts /2 (Legible or typed) 2 pts _/20__ 10 points Narrative note is in Head to Toe order Narrative Notes Head-to-toe assessment Head-to-Toe documented Abnormal results Assessment noted 10 pts Nursing Care Plan and ___/10_ Diagnosis for Chronic Pain 60 points (either a Correct Medical Diagnosis 15 pts Concept Map or a Patient Care Plan) Pathophysiology 15 pts ____/60 Concept Map Key Assessments 15 pts OR

60 points (either a At least 3 problems identified 15 Concept Map or a pts Patient Care Plan) Nursing Care Plan and Diagnosis Patient Care Plan for Chronic Pain 3 nursing diagnoses Related to” “As evidenced by” 18 pts 2 Outcomes specific, measurable, timed 8 pts 4-5 Interventions are logical, appropriate 15 pts 4-5 Scientific Rationales supporting each intervention 15 pts 2 Evaluations 4 pts