1. Students will work individually to present nursing care plan.
2. The Student will select a patient from the clinical setting with a medical/surgical condition.
3. The clinical instructor will approve the patient selected prior to beginning work on the presentation into insure a variety medical conditions/diagnoses are chosen and to avoid duplication.
4. A list of at least 3 references in the most recent APA format will be provided to the instructor. References must be recent (less than 5 yrs), nursing, and one research article.
â€¢ The care plan must be typed and appropriately formatted.
5. Identify and list all nursing diagnoses (problems that represent the patientâ€™s responses to the medical diagnosis).
â€¢ Care plans must include a minimum of one of each of the following nursing diagnoses
o Knowledge deficit (teaching need)
Nursing Diagnosis (NANDA) __________________________________________________
Related to (what factors are causing the problem) ______________________________________
As evidenced by (assessment findings- what did you discover that lead you to develop the nursing diagnosis) ____________________________________________________________
6. Develop the plan of care to address TWO of the identified problems with date, goals, outcomes, interventions, rationale, and evaluation criteria.
â€¢ Goals are broad
â€¢ Outcomes are specific, measurable, realistic and concise steps that the patient must accomplish to achieve the general goal. Outcomes should flow from the nursing diagnosis. You should aim to alleviate the problems identified in the â€œAs Evidenced Byâ€ portion of your nursing diagnosis.
â€¢ Interventions should include the rationale for doing them. Rationale must be based on data from the literature and references must be cited.
â€¢ Patient education and discharge planning should be included in the interventions.
â€¢ Evaluation criteria should state whether the outcomes are met. If outcomes have not been met, how are you going to revise the plan of care?
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Comments or questions are welcome.