Sample Care Plans

TheNursingStudentsPracticalGuide
toWritingCarePlans
ByLuanneBegin
PREFACE
Congratulationsforchoosingnursingasyourcareer!Thenursingprogramhere
atBristolCommunityCollegewillprovideyouwiththeacademicknowledge
andclinicalskillsyouneedtopasstheNCLEX,obtainyourlicense,andbegin
workingasaregisterednurse.Youwillfacemanychallengesoverthenexttwo
yearswhichwillrequireyoutoworkdiligentlyandconscientiouslyinorderto
meettheprogramobjectivesandachieveyourgoals.Youwillbeexpectedto
consistentlystrivefor,reach,andthenexceedyourpersonalbestasyouprepare
toentertheprofessionofnursing.TrustmewhenItellyouthatitcanbedone!
AsarecentgraduateofthenursingprogramIunderstand,fromastudentspoint
ofview,theuniquestrugglesyouarefacing.Icanrememberbeingexactly
whereyouare...intimidatedandoverwhelmedbythedauntingtaskofwriting
theperfectcareplan;or,ifnotperfect,atleastgoodenoughtoearnthatcoveted
andallimportantsatisfactoryfrommyclinicalinstructor.IoftenwishedIhad
anexample,ormodel,thatIcouldfollowwhichwouldassistmeinnavigating
mywaythroughthewritingrequirementsofthiscurriculum.Myfellow
studentsandIoftenremarkedonhowmucheasieritwouldbetowriteacare
planifonlywehadoneinfrontofustolookat!AsalongtimetutoratBristol
CommunityCollege,Ihavealwaysbeenpassionateabouthelpingother
students,andsoastheendofnursingschoolapproached,Idecidedtocreatethis
manualinthehopethatitwouldgiveincomingstudentsthekindofmodelmy
classmatesandIalwayswishedwedhad.
Thismanualhasbeendesignedtoassistyouinmeetingthewritingrequirements
ofthenursingprogram.Itisimportanttounderstandthattheclinical
componentofthiscurriculumisnotlimitedtosimplymasteringtechnicalskills
andprovidingdirectpatientcare;itrequiresyoutocriticallythink,andthen
writeabout,allaspectsofthatcare.Beforeyouevermeetyourpatient,youwill
beaskedtoconductresearch,collectdata,andpresent,inwriting,a
comprehensiveplandetailingyourunderstandingofthatpatient,includinghis
orhermedical,physical,emotional,andpsychosocialneeds,andhowyouplan
tomeetthoseneeds.
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Attheendofeachweek,youwillreflectonyourexperienceintheclinicalarea
andthenwriteaselfevaluationdocumentingyourthoughtsandfeelingsabout
yourperformance.Asatutor,Iunderstandthatmanystudentsareintimidated
by,orsimplyuneasyabout,theprospectofwriting.Worse,Ivemetquiteafew
whoclaimtohateit!Ifyoubelieveyourselftobeinoneofthesecategories,then
thismanualisforyou.Ithasbeendesignedtoeliminateanyreservationsyou
mayhaveaboutyourabilitytowritesuccessfully,andwithconfidence,by
showingyouexactlywhatyoucanexpectregardingcareplansandself
evaluations.Ihopeyouwillfindthisapracticalandvaluablelearningtoolas
youstriveforexcellenceintheclinicalarea.
Asyoumakeyourwaythroughnursingschool,strugglingandsacrificing,
pleasetakethetimetoremindyourself,often,thatyouhavebeenselectedfor
oneofthefinestnursingeducationprogramsinthisregionandthatyoucan,and
will,meeteachchallengesuccessfully,andberewardedbeyondmeasurefor
yourefforts.
LuanneBegin
StudentNurse,Classof2007
BristolCommunityCollege
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ACKNOWLEDGMENTS
Iwouldliketothankthefollowingpeople:
Dr.CynthiaHahn,formakingmelovechemistryandrecommendingmetothe
TutoringandAcademicSupportCentertherebyintroducingmetothe
wonderfulworldofbeingatutor.
Dr.RonaldWeisberger,whoseinfectiouspassionforpeertutoringinspiredmeto
helpothers,bothinsideandoutsidetheTASC.
ProfessorDianaDonnieMcGee,forencouragingmetobegintutoringinthe
WritingLabandinsistingthatIentertheCommonwealthHonorsProgramI
neverwouldhaveconsideredsuchathingwithoutherinfluence.
NicoleDeLano,forgenerouslysharingherFundamentalscareplans,beinga
friend,alwayshavingasmile,andfindingthetimetoinspireothers.
LynneCaron,forthewritingsamplessheprovidedtotheWritingLab;forthe
friendship,support,andencouragementthroughoutthese2years;foralways
pickingupthephonewhenIspeeddialedhernumber;and,ofcourse,forallthe
pancakesandcrazypneumonics.InotonlyearnedaNursingdegree,Igaineda
lifelongfriend.
Dr.HowardTinberg,forhistime,patience,anddedicationtothisstudent,and
towriterseverywhere;forhisspecialwayofhelpingawriterseethevalueof
theirwork;forhispraise,whichisalwaysgenerous,andhiscorrections,which
arealwaysgentle.Thisprojectwouldnothavebeenpossiblewithouthis
wisdom,insight,andguidance.
Finally,Ineedtothankmyfamily,forlivinginamessyhouseandeatingalotof
takeoutwhileIspenthourswiththecomputer.
TABLEOFCONTENTS
SectionOne:TheNursingProcess.................................1
Assessment....................................................1
Diagnosis......................................................1
Planning.......................................................2
Implementation.................................................3
Evaluation.....................................................3
SectionTwo:WritingaCarePlan..................................5
GettingStarted..................................................5
DataCollectionandOrganization.................................5
ConductingResearch............................................7
EvaluatingYourPriorities.......................................10
Revisions......................................................10
SectionThree:SampleCarePlans.................................12
Fundamentals:NUR11..........................................12
MedSurg:NUR51&52.........................................19
WhySuchLongCarePlans?.....................................39
SectionFour:SelfEvaluations....................................41
NUR11&12...................................................43
NUR51&52...................................................48
Afterword......................................................51
References......................................................52
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Section One: The Nursing Process
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Potter&Perry(2005)describesthenursingprocessasasystemtoorganizeand
delivernursingcare(p.279).Asyoumayalreadyknow,thenursingprocess
consistsoffivesteps:assessment,diagnosis,planning,implementation,and
evaluation.Whileyouhavestudiedeachoftheseaspectsofthenursingprocess
indepthduringyourcorecurriculum,Ithoughtitmightbehelpfultoprovidea
briefoverviewofhoweachofthesestepsappliestocareplanning.
Assessment
Assessmentisthedeliberateandsystematiccollectionofdata(Potter&Perry,
2005).Thisistheveryfirststepinwritingacareplan.Indeed,itwouldbe
almostimpossibletocreateamapofcareforapatientaboutwhomyouhaveno
information.Ontheeveningbeforeclinical,youwillwriteyourcareplanbased
entirelyoninformationyouhavegatheredfromthepatientswrittenrecords.
Althoughyouhavenotyetseen,touched,smelled,orlistenedtoyourpatient,
thisresearchofthepatientschartisassessment.Itallowsyoutounderstandthe
patientshistory,reasonforadmissiontothehospital,currentmedications,
laboratoryvalues,andcurrenthealthstatus.Youcannotproceedtothenextstep
incareplanningwithoutit.Pleasetakemyadviceandconductathorough
examinationofyourpatientsmedicalrecord;youdonotwanttobeathome
writingacareplanonlytorealizethatyouaremissingacriticalpieceof
information.
Diagnosis
Nursingdiagnosesareclinicaljudgmentsaboutactualorpotentialproblemsa
patientmaybefacing.Basedonyourassessment,youwillidentifythenursing
diagnosesmostappropriateforyourpatient.TheNorthAmericanNursing
DiagnosesAssociation(NANDA)istheorganizationthatdefinesandclassifies
nursingdiagnoses.Itisrequiredthatalldiagnosesincludedinyourcareplanbe
NANDAapproved.ThisisimportantbecauseNANDAprovidesacommon
languagethatallnursesuseandunderstand.Youhavepurchasedarequired
textthatprovidesyouwithacomprehensivelistofNANDAapproved
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diagnoses.Earlyoninyourcareerasanursingstudent,youareexpectedtouse
onlythattextasaresource.Later,youmaybeallowedtouseseveraldifferent
textsonnursingdiagnosesand/orcareplanning,dependingonyourinstructors
preferences,aslongasallyourdiagnosesremainNANDAapproved.Ifyour
instructordoesnotobject,youwilldefinitelywanttoinvestintwoorthree
nursingdiagnoses/careplanningbooks.
Inyourfirstyearyouwillbeginbyidentifyingonediagnosis,thenprogressto
identifyingthree,andthenfive.Inyoursecondyearyouwillidentifyfifteen.
Youwillalwaysbeginwiththenursingdiagnosiswiththehighestpriorityfor
thepatient,andproceedtolisttherestinorderofdecreasingpriority.Todothis,
usetheBasicHumanNeedslist(appendixA).Generally,anactualdiagnosis
takespriorityoverariskfordiagnosis.Forexample,ImpairedSkinIntegrity(an
actualproblem)wouldbeahigherprioritythanRiskforInfection(apotential
problem).However,therecanbeexceptions,andmostofthese,thankfully,can
bediscernedwithcommonsense.RiskforInjurywouldnaturallytake
precedenceoverActivityIntolerance.
Thewritingprocessisimportantwhenitcomestodiagnosis.Youmayfindit
helpfultofirstthinkaboutandthenwritedownonapieceofscrappaper,
withoutregardtowhatismostimportant,anyandallproblemsyoubelievethe
patientmayhavebasedonyourassessment.Fromthere,youcancriticallythink
aboutandbegintorankyourdiagnosesaccordingtopriority,beforecommitting
toactuallywritingtheminyourcareplan.
Planning
Theplanningphaseofthenursingprocessiswhenyouwilldecidewhichcare
measuresareappropriateforyourpatient.Eachnursingdiagnosislistedinyour
textwillhaveacorrespondinglistofinterventionsandrationales.Planningcare
involvescarefullyreadingthougheachlistedinterventionandaskingyourselfif
thatinterventioncanorshouldbecarriedoutwithyourpatient.Forexample,an
interventionlistedunderImpairedGasExchangereadsasfollows:Ifthepatient
isobeseorhasascites,considerpositioninginreverseTrendelenbergsposition
at45degreesforshortperiodsastolerated(Ackley&Ladwig,2006,p.439).
Now,ifyourpatientisnotobeseanddoesnothaveascites,thisinterventionis
notindicatedandshouldnotbeincludedinyourplanofcare.Toreiterate,
includeonlythosecaremeasureswhicharerelevanttoyourpatient.
Itisveryimportantthatyoulearn,earlyon,howtomakeyourinterventions
specifictoyourpatient.TrustmewhenItellyouthatyouwilllikelysave
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yourselfalotoftime,andpossiblyavoidhavingyourcareplanreturnedtoyou
forrevisions,ifyouareconscientiousaboutdoingthis.Asanillustration,
supposeyouhaveadiagnosisofAcutePainandoneofthelistedinterventionsis
administeranalgesics,asneeded.Whatyouwillneedtodoislookatyour
patientsavailablemedicationsforpainreliefandwritetheinterventionas
follows:administerDilaudid,2mg,IVq4hours@0800and1200.Noticethat
themedication,dose,route,andscheduleislistedandthatthetimesarespecific
totheshiftwhenyouwillbecaringforthepatient.Also,becognizantoftheuse
ofpronounsinyourinterventions.Useheorshewhereappropriate.Thislets
yourinstructorknowthatyouaretailoringyourcaretoyourpatient.Youwill
seemoreexamplesofspecificityasyoulookatthesamplecareplansinthis
manual.
Eachoftheinterventionsyouplanhasacorrespondingrationale;ascientific
explanationforwhythatnursingcaremeasureisappropriate.Beginninginyour
secondsemesteryouwillberequiredtolistarationaleforeachofyour
interventions.Manystudentsfindthistobeatediousandsomewhat
superfluousstep.Iurgeyoutoexamineeachrationalecarefully,asitisan
importantcomponentofyourlearning.Asnurses,itisessentialthatwe
understandnotonlyhowwedothings,butwhywedothings.Rationalesreflect
whatresearchhasproventobebestpractice.
Implementation
Implementationissimplycarryingouttheinterventionsyouhaveidentified
asbeingnecessaryforyourpatientscare.PotterandPerry(2005)teachesthat
preparationforimplementationensuresefficient,safe,andeffectivenursing
care(p.344).Partofyourpreparationinvolveshavingathoroughcareplan
completedbeforeyouarriveforclinical.Thisismandatory,andforgoodreason.
Howelsewouldyouknowwhattodowith,andfor,yourpatient?Whenyou
reportforclinical,youmustassess/reassessyourpatientinordertodetermine
whetheryourplannednursinginterventionsarestillappropriateornecessaryfor
thepatient.Implementationinvolvesmanystepsincluding,butnotlimitedto,
directcare,counseling,teaching,andpreventionofcomplications.Awell
thoughtoutandcomprehensivecareplanguidesyouthroughthesestepsand
helpsyoupracticeefficiently,safely,andeffectively.
Evaluation
Thefinalstepinthenursingprocess,evaluation,allowsustodetermine
whetherouruseofthenursingprocesswaseffective.Itasksthequestion,Did
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thepatient(orthepatientscondition/wellbeing)improve?Eachnursing
diagnosisyouidentifyhasspecificandmeasurabledesiredoutcomes.
Evaluationisbasedonwhethertheexpectedoutcomeswereachieved,andnot
onwhetherspecificinterventionswerecarriedoutorhelpful.Thisisan
importantdistinctionandoneyouneedtounderstand.Forexample,adiagnosis
ofImpairedPhysicalMobilitysuggeststhefollowingoutcomes:
Patientwill(givespecifictimeframe):
Increasephysicalactivity
Verbalizefeelingsofincreasedstrengthandabilitytomove
Demonstrateuseofadaptiveequipment(specifycrutches,walker,
etc.)toincreasemobility
Now,whilesomeofyourinterventionsforthisdiagnosiswillincludetreating
thepatientspainbeforeactivity,usingagaitbeltwhileambulatingthepatient,
andincreasingindependenceofADLs,evaluationisnotbasedonwhetherthese
caremeasureswerecarriedoutsuccessfully.Rather,youwillbeevaluating
whetherthenursingprocesswaseffectiveasawhole.Youwilldocument,on
yourcareplan,whetheryoubelieveyourassessments,diagnoses,planning,and
implementationmeasureswerecorrectandaccurate,andyouwillneedto
providerationalestosupportyourposition.Rememberthatyourjudgments
mustbebasedonwhetheryourpatientmet,orisprogressingtowards,the
expectedoutcomes.
Yourwrittenevaluationisaddedtoyourcareplanafteryouhavecompleted
yourfirstdayofclinical.Basedonyourassessmentsandevaluations,youmay
needtochangeyourprioritiesfordaytwo;someofyourdiagnosesmaystillbe
pertinentwhileothersmayneedtobechanged.Payattentiontothispart:please
resistthetemptationtoleaveyourtopfiveprioritiesunchangedsimplybecause
youcangetawaywithit!Ihaveknownsomestudentswho,becausetheydid
notwanttohavetoworkupanothernursingdiagnosis,wouldkeeptheirtop
fiveinspiteofthefactthatchangingsomeofthemwouldhavebeenmore
appropriate.Iunderstandthataddingmoreworktoyourcareplanafterhaving
littlesleepandalongdayatclinicalisthelastthingyouwanttodo.However,
trustmewhenIsaythatdoingjustthatcontributestoyourclinicaleducation
andmasteryofthenursingprocess.Ifyoufailtobeconscientiousinthisarea
youarecheatingyourselfandyourpatients.
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Section Two: Writing a Care Plan
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Hopefully,younowhaveabasicunderstandingofhowandwhyweusethe
nursingprocessinordertoplancareforourpatients.NowIdliketoturnyour
attentiontothemethodicalstepswetakeintheactualwritingofacareplan.
Everyonehasauniquewritingprocess;fromgeneratingideas,organizingyour
information,andwritingthebodyofyourworktorevisingandediting,the
writingprocesscanvarybetweenindividuals.Iencourageyoutousethe
processthatworksbestforyou.However,forthepurposesofthismanual,Iwill
outlinetheprocessthatIfound,throughtrialanderror,tobethemostthorough
andefficientforme.Bearinmindthatthisisonlyamodel,andnotaconcreteor
mandatorywaytoaccomplishyourgoal.
GettingStarted
Youhavearrivedatyourclinicalsitetopickupyourassignment,dressed
professionallyandwearingyourcrisp,whitelabcoat,lookingverymuchlikethe
healthcareprovideryouaredestinedtobecome.Ifyouareafirstyearstudent,
youareprobablyfeelingabitapprehensive,becauseyouareunfamiliarwiththe
unittowhichyouhavebeenassigned,andyouarehesitantaboutenteringthe
strangeandforbiddenoasisknownasthenursesstationandsimplyplucking
yourpatientschartfromitsdesignatedspotor,worse,rightfromunderthenose
ofthesecretary.(Donteverdothat,bytheway.Thesecretaryisakeeperof
importantinformationandcanbeyourbestfriendorworstenemy.Alwaysask
herpermissionbeforeremovingachartfromherdomain.)Takeadeepbreath
andrelax.Goaheadandremovethechartyouneed,justbesuretoleaveanote
initsspaceindicatingthatastudenthasthechartandwhereyouwillbeonthe
unit.Thisisextremelyimportant,incasesomeonefromthemedicalteamshould
needitforanyreason.
Youarenowreadytofindaquietspotandbeginresearchingyourpatients
medicalrecordinordertoobtaintheinformationyouneedtowriteyourcare
plan.Haveanotebookready,andstartwriting.
DataCollectionandOrganization
First,letmewarnyouthatwritingyourcareplanmaytakeyoueight,ten,or
eventwelvehours.Pleasedontbealarmed,asthisiscompletelynormal.
Becausewritingyourcareplancanbesotimeconsuming,ithelpstoorganize
yourdatainsuchawaythatmakesiteasytofindandrefertoonceyougethome
andbegin.IfoundthatIsavedmyselfalotoftimebyorganizinginformationin
alinearfashionthatparalleledtheformatofthecareplan.Here,Illsharewith
youmymethod,thoughagain,bearinmindthatyouarenotobligatedtofollow
myexample.
BasicInformation
Beginbywritingdownthefollowing:yourpatientsinitials,age,dateof
admission,dateofsurgery(ifapplicable),admittingdiagnosis,codestatus,and
anyallergies.Thisinformationwillbeincludedonthefirstpageofyourcare
plan.
Knowyourpatientsfullname,butdonoteverwriteitinyournotesoronyour
careplan.Rememberthatallinformationisconfidentialandthatyouaretaking
quiteabitofitoutofthehospitalandintoyourhome.Ifyournotesshould
somehowbemisplaced,lost,stolen,orleftlyingsomeplacewhereothersmight
readthemandthepatientsnameisonanypage,theirprivate,privileged
informationwouldbecompromisedandyouwouldbeinviolationoftheHealth
InformationPortabilityandAccountabilityAct(HIPAA).Pleasetakeevery
conceivablemeasuretoprotectyourpatientsidentity.
SignificantPastHistory(includingsocialhistory)
Noteanyhealthissuesormedicaldiagnosesthatyourpatienthas(suchas
diabetes,hypertension,coronaryarterydisease,emphysema,etc.)otherthanthat
whichbroughtthemtothehospital.Listanyprevioussurgeries.Takedown
theirsocialhistorysuchaswhotheylivewith,inwhattypeofhome,whether
theyhavefamilyorothersourcesofsupportandcare,ifthereisanadvanced
directiveinplaceand,ifso,whattype,anyculturalorreligiousconsiderations,
andwhethertheysmokeorusealcoholorillegaldrugs.
ReasonforPresentAdmission
Whyisthepatientinthehospital,howdidshecometobethere,andwhat
washerconditionuponarrival?Yournoteshereshouldfocusonthedetails
surroundingtheircurrenthospitalstay.
SignificantEventsSinceAdmission
Hereiswhereyouwillmakenoteofanysignificantornewfindingssincethe
patientcametothehospital.Besuretolookupanydiagnosticssuchasxrays,
ultrasounds,CTscans,MRIs,orEKGsandincludetheirfindings.Any
complicationsthathavedeveloped,additionalsurgeries,ornewtreatments
shouldalsobenoted.
LaboratoryValues
Makealistofallabnormallabvalues.Thosewithinnormalrangeshouldnot
beincluded.
Medications
Makealistofallthepatientsmedications.Althoughthereisusuallya
medicationlistinthechart,itisbettertoworkfromthepatientsmedication
administrationsheet.Itletsyouknowwhichmedshavebeendiscontinuedor
added,andismorecurrentthanthelistinthechart.Itmaybehelpfultomake
twomedicationlists:oneforscheduledmedsandanotherforPRNs.These
medsheetsarekeptindifferentlocationsatdifferentfacilities.Youwilllearn
theirlocationonyourfirstvisittoyourassignedunit.Aswiththechart,always
leaveanotethatyouhavethemedsheetsandwhereyouwillbeontheunit.
Kardex
TheKardexesarelocatedatthenursesstation,usuallynearthesecretary.
Thisiswhereyouwillfindinformationaboutthepatientsdiet,permitted
activity,IVfluids,whetherhehasacatheterinplace,ifheisonoxygen,typesof
dressingsandscheduledchanges,andanytestshemaybescheduledfor.
ConductingResearch
Onceyouhaveallthenecessaryinformation,itstimetogohomeandbegin
doingresearch.Again,yourpreferredwritingprocessshouldbeapplied.You
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maychoosetodoallyourresearchbeforeyoubeginwriting,oryoumaydoitas
youwrite.Eitherway,clearsomespacearoundyouandpreparetohaveseveral
booksavailableatarmsreach.
ResearchingYourPatientsCondition
Youneedtohaveatleastabasicunderstandingofanymedicalconditionor
surgeryaffectingyourpatient.Inyourfirstsemesterofnursingyouarerequired
towriteout,verbatim,thedefinitionsofthesemedicalconditionsandsurgeries,
citingyoursources.Inlatersemesters,youwilllikelypossessaknowledgebase
aboutmostofthehealthcareissuesyouwillbedealingwithinclinical.
However,whenyoudontknow,besuretolooktheissueupandunderstandit
beforeyouwriteyourcareplanandreporttoclinical.Sourcesforthis
informationincludeyourFundamentalsandMedicalSurgicaltextbooks,and
MosbysMedicalDictionary.
ResearchingNursingDiagnoses
YourNursingDiagnosisHandbook,byBettyAckleyandGailLadwigisthe
primarysourcefornursingdiagnoses.First,criticallythinkandtrytoidentify
whatyourpatientsdiagnosesmightbe.Then,openupAckley,whereyouwill
findanalphabeticallistofmedicalconditionsandsurgeries,andcommon
nursingdiagnosesforeach.Asyouconsideradiagnosisforyourpatient,findit
inAckleyandreaditsdefiningcharacteristicsandrelatedfactors.Simplydoing
thatshouldletyouknowifthediagnosisisappropriateforyourpatient.
Onceyouhavecompletedyourlistyouwillworkupyourtopdiagnoses.
Thisincludeswritingoutallassessments,interventions,andrationales.Inyour
firstyear,youarerequiredtociteyoursourceforthediagnosisandallrationales.
Asmentionedpreviously,takethetimetoreadthrougheachintervention,
chooseonlythosethatareappropriatefor,andmakethemspecificto,your
patient.
ResearchingLabsandDiagnosticTests
Asofthiswriting,theresourceforthisinformationisAManualofLaboratory
andDiagnosticTestsbyFrancesFischbach.Youwillutilizethisbooktoevaluate
laboratoryvaluessuchasredbloodcellcount,hemoglobin,hematocrit,white
bloodcellcount,urinalysis,electrolytes,etc.Itprovidesindicationsastowhya
particularlabvaluemaybehighorlow.Inaddition,itoutlinesproceduresfor
collectingspecimens.Diagnostictestsarealsoexplained,withinstructionsfor
preparingthepatientfortestingandhowtocareforthemafterwards.Many
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times,whenyoureadadiagnosticreportinthepatientschart,itwillprovidean
interpretationofthefindings.Ifbyrarechancethisisnotthecase,youmaybe
abletodiscernanexplanationinthetextbook.However,ifyouarenotsure
whatthefindingsofadiagnostictestmaymean,donttrytoguess.Bringyour
questiontoyourclinicalinstructor,whowillassistyouindeterminingthe
significanceofanyfindings.
ResearchingMedications
YouwillresearchmedicationsinSpringhousesNursesDrugGuide.Foreach
medicationonyourlistyouwillneedtoprovideitsgenericandtradename,
dose,route,schedule,timesdue,pharmacologicalclass,therapeuticclass,mode
ofaction(chemicaleffect),andsafedose.Inaddition,youmustprovidethe
reasonthepatientistakingthemedication,potentialsideeffectsandinteractions,
andallnursingresponsibilitiesrelatedtoadministeringthatmedication.
Ifyouprepareyourcareplansonthecomputer,Istronglyrecommendthat
youkeepadatabaseofeverymedicationthatyouresearchandwriteup.You
willlikelyadministerseveralmedicationsrepeatedlythroughoutyourtwoyears
innursingschool.Youwillsaveyourselfanincredibleamountoftimeifyou
copyandpastethesemeds;youwillthenonlyneedtochangethedose,route,
schedule,timesdueandreasonthepatientistakingthemed,asnecessary.Be
advised,though,thatclinicalinstructorsfrownonthispractice.Theirconcernis
thatyouarenotthoroughlypreparedtogivethemedicationandmaybe
cheatingyourselfoutofvaluablelearningbyskippingtherepetitionoflooking
upandwritingoutthemedeachtimeyouhavetogiveit.This,ofcourse,isa
completelyvalidargument.However,asbusynursingstudentsyourtimeis
valuableandyouneedtouseitaseffectivelyaspossible.Keepingadatabaseof
medsisonewaytoaccomplishthat.Justdontdoitattheexpenseofyour
patients.Bediligentandconscientiousandknoweverythingyouneedtoknow
tosafelyadministerthatmedication.Yourpatientswellbeing,indeedtheir
lives,dependsonyourdoingthat.Also,whencopyingandpasting,bearin
mindthatyourinstructormayquizyouaboutthatdrug,andifshedoes,youd
betterhavetheanswerstoherquestions.Ifyoudont,youmayearnyourselfa
clinicalwarning.
WritingUpDiagnoses,Interventions,andRationales
Beginninginyoursecondsemesteryourcareplanwillhavethreecolumnsfor
this.Inthefirstcolumnyouwillwriteyourdiagnosisintwoorthreeparts,
dependingonyourinstructorspreference.Forexample,atwopartdiagnosis
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wouldreadasfollows:ImbalancedNutrition,lessthanbodyrequirementsr/t
lossofappetite.Thisstatesthediagnosisandthefactoritisrelatedto.Athree
partdiagnosisdoesthesame,withtheadditionofstatingthedefining
characteristics.Athreepartdiagnosis,then,wouldreadlikethis:Imbalanced
Nutrition,lessthanbodyrequirementsr/tlossofappetitem/brecent30pound
weightloss.Yournursingdiagnosisbookprovidesalistofrelatedfactorsand
definingcharacteristicsforeachdiagnosis.Underyourdiagnosisyouwill
providealistofsubjectiveandobjectivedatatosupportit.
Themiddlecolumnisforlistingyourinterventions.Youwillberequiredto
breakthemdownintothreesections,whichwilldifferinyourfirstandsecond
year.Thismayseemabitconfusing,butwillbeexplainedandbecomeclear
whenyoulookatthesamplecareplansprovidedinthismanual.
Thethirdcolumnisforlistingtherationaleforeachintervention.Each
interventionandcorrespondingrationaleshouldbenumberedandlineupnext
tooneanotherineachcolumn.Thisorganizesyourcareplan,makesitneatand
presentable,andsavesyourinstructorfromeyestrain.
EvaluatingYourPriorities(NUR51&52)
Afterthefirstdayofcaringforyourpatientyouwillberequiredtowritean
evaluationoftheachievementofyourpriorities.Yourprioritiesfordayoneare
yourtopnursingdiagnoses(threeinyourfirstyear,fiveinyoursecond).
Evaluatingyourachievementrequiresyouthinkaboutwhetherthatdiagnosis
wasaccurate,whyyoubelieveitwasorwasnot,andwhatyourplansare
regardingthatdiagnosisfordaytwo.Shouldyoucometorealizethatoneof
yourtopdiagnosesisnolongerappropriate,youwillneedtomoveothersupthe
listorreplaceitwithanewdiagnosis.Youwill,ofcourse,havetowriteupthe
interventionsandrationalesforanyadditionsorchangestothetoppriorities.
Revisions
Youmaymakerevisionstoyourcareplanatanytimebeforegivingittoyour
instructor.Beprepared,though,tohanditoverattheendofyoursecond
clinicalday.Hopefully,itisorganized,thorough,detailed,andaccurateand
comesbacktoyouwiththewordSatisfactorywrittenacrossthetop.Ifit
doesnt,dontbediscouraged.Mostinstructorswillallowyoutomakerevisions
wheretheyhaveindicated,andifyoudothatandturnitbackintheywillaccept
itandchangeittosatisfactory.Sometimes,evenafterrevisions,acareplanjust
cantbesalvagedandyourinstructorwillnotacceptanymorechanges.Atthat
point,youwillsimplyhavetoputthatcareplanbehindyouandputyourbest
effortsintothenextone.
Aswithanynewchallenge,whenyoufirstbeginwritingcareplansitmay
takesometimetogetthingsexactlyright.However,witheachpassingweek
therewillbeimprovementuntilyouarewritingcareplanswithconfidenceand
ease.Asyouadvancethroughnursingschooltheacademiccurriculumand
clinicalrequirementsbecomemorechallenging.However,althoughthepatients
youcareforbecomemorecomplexand,therefore,thecareplansmore
complicated,theyactuallybecomeeasiertowrite.Learningisbasedonprevious
knowledgeandexperience,andasyouprogressthroughnursingschoolyouwill
findyourselfassimilatingdatamorequicklyandefficiently,andcompletingyour
careplansinamoretimelymanner.Everyonestartsoutslowly,buttime,
practice,andexperiencewillhaveyouwritingcareplansthatnotonlyprovidea
mapofcareforyourpatients,buthelpyougrowasaproviderofthatcareinthe
professionofnursing.
11
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Section Three: Sample Care Plans
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
InthissectionyouwillfindsamplesofcareplansforNursing11
(FundamentalsofNursing)andNursing51and52(NursingCareoftheAdult).
IregretthatIcouldnotincludesamplecareplansforNursing12(ParentChild
Nursing).Asyouwillsoonlearn,ifyouhaventalready,obstetricsand
pediatricsarespecializedareasandtheprocessofwritingcareplansand
obtaininginformationforthemisvastlydifferentfromthatwhichIhave
outlinedhere.However,therearecopiesofobstetric(laboranddelivery,
postpartum,andnewborn)andpediatriccareplansavailableforreviewinthe
writinglab.
Fundamentals:Nursing11CarePlans
WhatfollowsisasampleofaNursing11careplan,whichconsistsofthree
phases.Asyousuccessfullycompleteonephase,youwillmoveontothenext,
untilyouarewritingacompletecareplan.Inthesample,Ihaveindicatedon
eachpagewhichphaseitispartof.
Asyouwillsee,pageoneconsistsofblockswhichareselfexplanatory.You
willsimplyneedtofilltheminwiththeappropriateinformation.
Pagetwolistsallyourpatientsdiagnosesandsurgeriesanddefinesthem
Themedicationpagelistsallmedicationsthepatientistaking.Ihave
workeduponlytwo,foryoutouseasamodel.
Next,thereisapagerequiringyoutolistyourtopthreenursingdiagnosesfor
eachdaythatyouwillbeprovidingcare,andasectionforprovidingsocio
culturalinformation.
Finally,thereisasampleofanursingdiagnosisanditsinterventions.Asyou
willsee,yourinterventionsmustbebrokendownintothreesections:
Assessments,Interventions,andTeaching.Someinformationmayberepeatedin
morethanonesection,whichisacceptable.Again,Ihaveworkeduponlyone
diagnosis.Followingthemodelprovided,youshouldhavenodifficulty
completingallthreeofyourrequireddiagnoses.
12
BristolCommunityCollege
NUR11:NURSINGCAREPLANPHASEI

Rm. # I & O Wednesday/Findings
Tuesday
Physician
I:
Nurse
Code status O:
Precautions Wednesday
Allergies I:
O:
T
P
R
B/P
T
P
R
B/P
STAT or One Time
Medications
List all medications that you will administer & times due
IV Therapy (Solution and Rate)
Scheduled Medications PRN Medications
Clinical Date
IV Therapy Assessments Site
Flow
Complications
Neurological Checks (PERRLA)
Other
Extremities (Pulses, CMS,
Homan's)
Wednesday
Tuesday/Findings
List the materials needed and any
procedure steps
Treatments/ Procedures Specimens to obtain & Diagnostic
procedures to be done on your time
Vital Signs
Tuesday
Lung Sounds O2 Saturation
Bowel Sounds (Assess all 4
quadrants)
Last BM
LOC,
Mental Status,
Orientation
Pain Assessment
Admitting Diagnosis
Secondary Diagnoses
Student name: Patient initials:
Diet
Hygiene
Activity
Assessments
DefinitionofMedicalDiagnosesandSurgery
AdmittingDiagnosis
RenalFailure:theinabilityofthekidneytoexcretewastes,concentrateurine,andconserveelectrolytes.Thecondition
maybeacuteorchronic(MosbysMedicalDictionary,p.1485).
SecondaryDiagnoses
Angina:aparoxysmalthoracicpaincausedmostoftenbymyocardialanoxiaasaresultofatherosclerosisorspasmofthe
coronaryarteries.Thepainusuallyradiatesalongtheneck,jaw,andshoulderanddowntheinneraspectoftheleftarm.
Attacksofanginapectorisareoftenrelatedtoexertion,emotionalstress,eating,andexposuretointensecold.Thepain
mayberelievedbyrestandvasodilationofthecoronaryarteriesbymedication(Mosby,p.96)
Arthritis:aninflammatoryconditionofthejoints,characterizedbypain,swelling,heat,redness,andlimitationof
movement(Mosby,p.136)
AtrialFibrillation:acardiacarrhythmiacharacterizedbydisorganizedelectricalactivityintheatriaaccompaniedbyan
irregularventricularresponsethatisusuallyrapid(Mosby,p.154)
CongestiveHeartFailure:anabnormalconditionthatreflectsimpairedcardiacpumping.Itscausesincludemyocardial
infarction,ischemicheartdisease,andcardiomyopathy(Mosby,p.416).
SickSinusSyndrome(SSS):acomplexofarrhythmiasassociatedwithsinusnodedysfunction.Theconditionmay
resultfromavarietyofcardiacdiseases,rangingfromcardiomyopathiestoinflammatorymyocardialdisease.Itismost
commonlyrelatedtoeitherintermittentSAblockorinadequateSAconduction.SickSinusSyndromeischaracterizedby
severesinusbradycardia,eitheraloneoralternatingwithtachycardia,oraccompaniedbyatrioventricularblock.The
mostcommonsymptomsarelethargy,weakness,lightheadedness,dizziness,andsyncope(Mosby,p.1580).
Surgeries
Pacemaker:electricalapparatususedtoincreasetheheartrateinseverebradycardiabyelectricallystimulatingtheheart
muscle(Mosby,p.1259).
THISPAGEISINCLUDEDINPHASEONE14
Citeyoursource!
NURSING11CAREPLANPHASETWO
Medications
Nameofdrug
Dose
Route
Timesdue
Classifications
SafeDose
DrugAction
Reasonpatientison
medication(bespecific)
List3sideeffects
Listallsignificantnursing
actionsrelatedtothe
administrationofthismed
spironalactoneAldactone
25mg
PO2xdaily
0800/2000
Pharmacologicalclass:
potassiumsparingdiuretic
Therapeuticclass:
managementofedema,
antihypertensive,diagnosisof
primaryhyperaldosteronism,
treatmentofdiureticinduced
hypokalemia
Safedose:upto100mgdaily
Drugaction:antagonizes
aldosteroneindistaltubule;
promoteswaterandsodium
excretionandhinders
potassiumexcretion,lowers
bloodpressure,andhelpsto
diagnoseprimary
hyperaldosteronism
Observeforheadache,
diarrhea,dehydration
1.Givedrugwithmealsto
enhanceabsorption
2.Protectdrugfromlight
3.Monitorelectrolytelevels,
fluidintakeandoutput,and
BPqshift(0800/1600/2400)
Reasonptisonmed:totreat
hypertension
4.Bealertforadverse
reactionssuchas
hyperkalemia,angioedema,
confusion,anddrowsiness
5.Bealertfordrug
interactionssuchaspotassium
chloride

potassiumchlorideKTab Drugaction:aidsin
transmittingnerveimpulses,
contractingcardiacand
skeletalmuscles,and
maintainingintracellular
tonicity,cellularmetabolism,
acidbasebalance,andnormal
renalfunction.Replacesand
maintainspotassiumlevels.
ObserveforEKGchanges,
abdominalpain,weaknessof
limbs
20mEq
POdaily
0800
1.Givecautiously;differentK
supplementsdelivervarying
amountsofK.Neverswitch
productswithouta
prescribersorder
Pharmacologicalclass:
potassiumsupplement
Therapeuticclass:mineral
2.Givewithoraftermeals
withafullglassofwater Safedose:upto50mEqtwice
daily
Reasonptisonmed:CHF
3.Makesurepowdersare
completelydissolved
4.Monitorrenalfunction,fluid
intakeandoutput
5.MayinteractwithKsparing
diuretics
Note that there may be an

interaction between these
meds. You may want to
emphasize this in red, or
by marking it with a
highlighter
Number all nursing actions.
You will find these listed with
each med under nursing
process
Generic and
trade names
Always preface side
effects with observe for
Meds are part
of phase 2
NUR11NURSINGCAREPLAN
THREEMOSTIMPORTANTNURSINGDIAGNOSES
IncludepagenumberfromNUR11requirednursingdiagnosisbook
Tuesday
1. Oxygenation:DecreasedCardiacOutputr/tdysrhythmia(p.136)
2. Elimination:ImpairedUrinaryEliminationr/tdiuretictherapy(p.787)
3. Safety:ImpairedSkinIntegrityr/tprolongedimmobility(p.584)
Category of
basic human
needs
Related to (what is causing
this problem)
Diagnosis
Cite page
number
Wednesday
1.
Your diagnoses may remain the same or, after you have
reassessed the patient, change for day 2.
2.
3.
ImplicationsforNursingCareRelatedtoCulturalBackground
(considerlanguage,religion,ethnicity,andsocialorganization)
PatientisEnglishspeakingandlivesaloneinasinglestoryhouseandreceives
mealsdailyfromMealsonWheels.Sheisaretirednurseandisactiveinher
community.SheisadevoutRomanCatholicandattendsMassregularly.
THISISPARTOFPHASETWO
16
NursingDiagnosis NursingInterventions
Assessments DecreasedCardiac
Outputr/tdysrhythmia 1. Assessrateandqualityofapicalandperipheralpulsesqshift
@0800,1600,2400 (Carpenito,p.136)
2. AssessBPandanyorthostaticchangesqshift@0800,1600,
2400,andbeforeambulatingpatient
3. Assesslungsoundsqshift@0800,1600,2400.Noteany
occurrenceoforthopnea
4. Assessforcomplaintsoffatigueandreducedactivity
tolerance.Determinewhatlevelofactivitycausesfatigueor
exertionaldyspnea
5. Assessurineoutputqshift@0800,1600,2400
6. Assessforanychangesinmentalstatuswhileperforming
neurochecksqshift@0800,1600,2400
7. Assessoxygensaturationwithpulseoximetryqshift@0800,
1600,2400andduringactivity
Interventions
1. Monitorandrecordintakeandoutputqshift@0800,1600,
2400
2. Monitorforsymptomsofheartfailureanddecreasedcardiac
output;listentoheartandlungsounds;noteanyorthopnea,
dyspnea,fatigue,weakness,adventitiouslungsoundssuch
ascracklesorrales
3. Observeforchestpainordiscomfort;notelocation,radiation,
severity,quality,duration,andassociatedmanifestations
suchasnausea,indigestion,anddiaphoresis;alsonote
precipitatingandrelievingfactors.
4. MonitorlabworksuchasCBC,sodium,potassium,and
creatininelevel
5. Graduallyincreaseactivitywhenthepatientsconditionis
stabilizedbyencouragingslowpacedorshortperiodsof
activitywithfrequentrest:observeforsymptomsof
intolerance
a) TakeBPandpulsebeforeandafteractivityandnote
changes
6. Monitorbowelfunction.Administercolace100mgPOdaily
@0800,asprescribed
a) Cautionpatientnottostrainwhendefecating
b) Haveherusethecommodefortoiletingandavoiduseof
bedpan
7. Observeforsyncope,dizziness,palpitations,orfeelingsof
weaknessassociatedwithanirregularheartrhythm
8. Administerspironolactone25mgPO@0800;potassium
chloride20mEqPO@0800asprescribed
9. Observeforsideeffectsfromcardiacmedications
Teaching
1. Teachstressreductiontechniquessuchasguidedimagery,
List specific meds
related to this
diagnosis
List the specific
labs you will
monitor
List all
assessments
you will
perform. Be
specific about
times.
controlledbreathing,musclerelaxation
2. Explainnecessaryrestrictions,includingtheneedfora
sodiumrestricteddiet,guidelinesonfluidintake,andthe
avoidanceoftheValsalvamaneuver
3. Teachtheimportanceofpacingactivities,includingvolunteer
work,andtheneedtorestbetweenactivitiestoprevent
becomingoverfatigued
4. Teachherabouttheactions,sideeffects,andimportanceof
takingcardiovascularmedications
5. Providespecificwrittenmaterialsandselfcareplanforher,
orhercaregivers,touseasareference
6. Instructherontheimportanceofgettingapneumonia
vaccine(usuallyonceperlifetime)andfluvaccines(yearly)
asprescribedbyherphysician
Reference to
volunteer work is
specific to this
patient.
THISISINCLUDEDINPHASETHREE
18
MedSurg:Nursing51&52CarePlans
Followingisasampleofanursing51medicalsurgicalcareplan.Youwill
noticethatitcontainsmoreextensiveinformationthantheNUR11careplanand
isquitedifferentinformatfromtheOBandpediatriccareplans.
AswithNUR11,yourinterventionsmustbebrokendownintosections.
However,formedsurgtheyshouldappearasfollows:Assess,Prevent,and
Evaluate.UnderAssessyouwilllist,ofcourse,allnecessaryassessmentsforthat
diagnosis.UnderPrevent,listallinterventionsyouplantoperforminorderto
preventfurtherdeteriorationof,andhopefullyimprove,yourpatientscondition
andwellbeing.UnderEvaluateyouwilllisttheexpectedoutcomesforyour
diagnosis.
Inordertogiveyouacomprehensivepictureofwhatyourcareplanshould
looklike,thesampleIhaveprovidedispresentedinitsentirety.
19
BRISTOLCOMMUNITYCOLLEGE
FallRiver,MA
CAREPLAN
NUR51&52
Name: Patientsinitials: Diagnosis:cellulitis,Lupperthigh
Date: Age:44 Surgery:N/A
AdmissionDate: Allergies:morphine,
cephalosporins
Dateofsurgery:N/A
SignificantPastHistory(includingsocialhistory)
Patientisamarried44y/ofemale.Historyrevealsarecentcervicalspineinfection
resultinginafractureandsubsequentquadriplegia.Thecspineinfectionisspeculated
tohavearisenfromanundiagnosedcystwhichburst.Patienthadalonghospitalization
followedbyrecuperationat______________NursingHome,whereshehasbeen
residingforthelast2months.Herhusbandisdisabledandtheyrecentlylosttheir
home,duetotheirrespectivemedicalconditionsandfinancialhardship.Their2
adolescentchildrenarestayingwithrelatives.Thereisadistanthxofdrugabusewhich
predatesthecspineinfectionbyseveralyears.Patientidentifiesherreligionas
Catholic.Sheisafullcode,astherearenoadvancedirectivesinplaceatthistime.
ReasonforPresentAdmission
Patienthaspressureulcersonbothshoulderblades,coccyx,andRhip.Herlefthipand
theanteriorandlateralaspectsoftheLthigharered,edematous,andwarmtothe
touch.Shewascomplainingofneckspasms,morepronouncedontheleftthantheright.
Shedevelopedafever,hermentalstatusappearedtodeteriorateandshewasbroughtto
theERat__________Hospital.Hertemperaturewasrecordedat103.5.Alumbar
puncturewasperformed;theresultswerenegativeformeningitis.Shecomplainsofnot
feelingwell,andbeingachyalloverx34days.Thereissomedistensionofthe
abdomen,buttherehavebeennochangesinbowelhabits.Diagnosisiscellulitisofthe
Lupperthigh.
D5NS@100cc/hr
Foleycatheter
Regulardiet
FlushGtubewith30ccH2Obeforeandaftermeds
Coccyx:aquagelwith1rollofgauze,coverwithDSD
This information will be found on the

Kardex. There is not a specific place for
it on your care plan, so you may write it
in anywhere.
TIP: orders and treatments such as
these can change at any time it is best
to re-check the Kardex on the morning
of clinical, and write these on your care
plan when you come in, rather than
typing themin the night before.
SignificantEventsSinceAdmission
Date:CXRrevealscephalizationwithinterstitialopacities.Mayreflectvolumeoverload
orunderlyinginterstitiallungdisease.Nopleuraleffusion,consolidationor
pneumothorax.
Date:AttempttoinsertPICClinetoleftantecubitalregionunsuccessfulafter3attempts.
NursetoconsultwithMDaboutalternativeoptions
Date:Patientcompletedassessmentformsforpainclinic.Awaitingassessmentby
woundclinicandPT/OT
Date:TriplelumencentrallineplacedRUC.PlacementcheckedbyportableCXR
SummaryofPatientStatusatEndofDay1
Vitalsigns:0700101.3771694/5995%RA
1130101.1751789/5497%RA
Patientalert&orientedx3formostoftheday,withperiodicnaps.Lungsareclearbilaterally;
abdomensoftwithpositivebowelsoundsx4quadrants.Calvesappearnormalwithnoredness,
edema,orwarmth;positivebilateralpedalpulses.Thereisasmallareaofrednessonthetipof
theRgreattoe,whichIoutlinedwithmarker,nursemadeaware.Heelsintactwithnoredness.
Skinisdrywithsomeflaking.Lipsaredry,butinspectionoftheoralmucousmembranesshows
adequatemoistureandnolesions.ThereismarkedrednessandheatovertheLhipandthe
anteriolateralaspectoftheLupperthighrelatedtothecellulitis.Entireareacircledbynurse,in
ordertoevaluateanyrecessionorprogression.Woundtococcyxnotinspected,aspatientis
awaitingaconsultfromthewoundclinic.Dry,sterile4x4replacedover1cmcircularwoundon
Rshoulderblade;someserosanguinousdrainagepresent.Patientc/odiscomfortofherneckand
back;performedfrequentpositionchanges,takingcaretoensureproperbodyalignment.Area
aroundFoleycatheterinspectedandcleaned;noredness,edema,dischargeorodorpresent.IV
siteonRhandpatent.Patientc/oburninganditchingwhileUnasynbeinginfused.Site
inspectedbynurse;nochangeoftemperatureorcolorofskin,noedema.Infusionslowedand
warmpackappliedtosite.Patientate100%ofbreakfast,30%oflunch.POfluidintakewas
approximately860ccs.Urineoutputof450ccs(64cc/hr),appearanceyellowandconcentrated.
Patienthad1largebowelmovementmidmorning.Afternoonvitalsrevealedpatienttobe
febrile@101.1withaBPof89/54.NursemadeawareandinformedmethatBPconsistentlyruns
low.AnorderforTylenol1000mgPOq6hourswaswrittentoday.
Day2:
Vitals:070099.78020102/6996%RA
110098.77418122/6996%RA
Vancomycin:peak32.6,trough8.0
Woundcareconsult:treatmentplanistochangedsgtococcyx2xday.IrrigatewithsterileH2O,
coatpackingwithtripleantibiotic,coverwithDSD.
Youshouldalsolistyourday2labs!
21
This section consists of the
findings of your head-toe
physical assessment.
Your day 2 vitals and any new
treatments will be written in by hand
before you pass in your care plan
PriorityNursingDiagnosisObjectiveTestData
W TH
Test&Norms Results&
Dates
Interpretation
1
10
11
10
11
ImpairedSkinIntegrityr/t
immobility,pressure
RiskforInfectionr/topen
wounds
RiskforIneffectiveTissue
Perfusion,peripheralr/t
interruptedvenousflow
secondarytoprolonged
immobility
Powerlessnessr/tlossoffunction
ChronicSorrowr/tpermanent
disability
ChronicPainr/tdiseaseprocess
DisturbedBodyImager/ttrauma
(quadriplegia)
IneffectiveProtectionr/t
abnormalbloodprofile(seelabs)
ImpairedBedMobilityr/tneuro
muscularimpairment
(classificationlevel4:doesnot
participateinactivity)
ImbalancedNutrition,lessthan
bodyrequirementsr/tlossof
appetite(wgt:125lbsBMI:20.2)
SelfcareDeficit,
bathing/hygiene,
dressing/grooming,toiletingr/t
neuromuscularimpairment
Sodium
135145
Chloride
96107
Potassium
3.55
Glucose
70110
BUN
821
Creatinine
0.51.2
Prealbumin
1836
Protein(CSF)
1545
WBC
311
MCV
8296
Neutrophils
4283%
Lymphocytes
1347%
213:131
214:135
213:96
214:102
214:3.2
213:121
Slightlydecreaseddueto
sweating(febrilex3
days),deficientdietary
intake
Slightlydecreasedwith
sodiumloss
Slightlydecreasedto
sweating,draining
wounds,inadequate
dietaryintake
Slightlyelevated;maybe
r/tmeds
Decreased;maybedueto
lowproteinintake,
malnutrition
Decreasedduetolow
protein,decreased
musclemass,
malnutrition
Decreasedduetolow
protein,malnutrition
Notsignificant.Level
mustbemoderatelyto
markedlyincreasedto
suggestinfection
213:5
214:5
213:0.4
214:0.3
213:17.7
213:45.8
213:15.4
Acuteinfection(cellulitis)
214:7.3
RBCsareslightly
microcytic
213:80.2
214:81.7
Acute,localizedinfection,
inflammation
213:88%
Decreased;maybedueto
debilitatingillness
213:5%
214:6.9%

Include
specifics
In order of priority; may
change for day 2
Mayber/tpotassiumloss
213:>9 12
13
14
15
12
13
14
15
SexualDysfunctionr/taltered
bodyfunction
DeficientDiversionalActivityr/t
disability,environment
RiskforAutonomicDysreflexia
r/tspinalinjury
RiskforDisuseSyndromer/t
paralysis
UrinepH
56
RBC
3.965.27
HGB
11.615.5
HCT
3547
214:3.78
Relatedtoirondeficiency
214:10.5
214:30.9
Duetoanemia
Indicatesanemia.Likely
irondeficient(if
microcytic,RBCsand
HCTdonotparallel)
23
Although not required, you
may want to type lab values
in a different color, or mark
themwith a highlighter to
help themstand out for easy
reference.
NursingPrioritiesforDay1 EvaluationofPriorityAchievement NursingPrioritiesforDay2
immobility,pressureonbony
prominences
wounds
interruptedvenousflow
immobility
Powerlessnessr/tlossof
function
Thiswasanaccuratediagnosisand
importantpriority.Patienthasan
openwoundonthecoccyx,and
woundsonbothshoulderblades.
Herimmobilitypresentsachallenge
inthatitmaybedifficulttopromote
healingandpreventnewwounds,
astheptisalmostconstantlyonher
back.
Patientatincreasedriskfor
infectionofherwounds,particular
lytheoneonhercoccyxduetoits
depthandproximitytotheanus
(sheisoccasionallyincontinentof
stool)
Iamnotentirelyconfidentthatthis
diagnosisisatop5priority.There
areotherswhichcouldeasilymove
upthelist.Patientisbeingtreated
withLovenox40mgSCdaily;
however,sheisunabletoperform
ROMexercises,andtheabsenceof
compressionstockingsconcernsme.
DevelopmentofaDVTand
progressiontoapulmonary
embolismisarealdanger...
symptomscoulddevelopsilently,as
theptisunabletoreportchangesin
sensation
Powerlessnessisahugeissuewith
thispt.Shedemonstratesbehaviors
atthelow,moderate,andsevere
level.Herlackoffunctionisonly
onecontributingfactor(sheis
completelydependentonothersfor
care).Anequalportionisdirectly
relatedtoherperceivedlackof
controloverdecisionsandwhat
happenstoher.Shehasbeen
Thisremainsapriorityat#1.
Iwouldliketoviewand
measureherexisting
wounds,ifthewound
consultanthasnotdoneso
(ptdueforconsultonday
one,afterIleft)
Thisdiagnosisremainsat#2,
forthereasonsstated.Iwill
checkherfrequentlyfor
incontinenceandcleanher
promptlytoavoid
contaminationofherwound
Iwillkeepthisdiagnosisat
#3,abovepowerlessnessand
chronicsorrow,onlybecause
itispotentiallylife
threatening.Iwillspeakto
herprimarynurseabout
obtaininganorderforTEDS
orpneumaticstockings
Thisdiagnosisremainsat#4.
Iwouldliketoinitiatea
consultwithapsychiatric
nurseaswellasmake
inquiriesaboutherpossible
optionsforadifferentcare
facility(shementioneda
facilitywhereshefeltbetter
caredfor).
If your diagnosis remains

the same, what do you plan
to do for the pt on day 2? If
it changes, list the newone
in this column and provide a
rationale for the change
Evaluate whether
your diagnosis was,
or was not,
appropriate, and why
ChronicSorrowr/t
permanentdisability
unsuccessfulinherattemptstogain
informationabouthertreatment
goalsanddischargeplans,
particularlyasitappliestothe
nursinghomewhereshecurrently
resides.Shefeelsignoredand
seemsresignedthatitisuselessto
attempttogaininformation.She
appearstohaveanexternallocusof
control.
Patientexhibitsbehaviorsconsistent
withthisdiagnosis.Shehasperiods
ofsadness,crying,anger,
frustration,apathy,etc.Im
concernedthatsheissufferingfrom
majorclinicaldepression.
Thisdiagnosisstaysat#5.I
wouldliketoexplorewith
thepatientherfeelingsabout
counseling/medicationfor
depression.Iwonderifa
combinationofconsistent
cognitivebehavioraltherapy
andantidepressant
medicationmightpromote
readinessforenhanced
coping.
25
MedicationOrder Rationaleforuseinthis
patient
NursingCareMeasures
fentanyl patch Duragesic
100 mcg transdermal q 3 days
Opioid analgesic
Anesthetic
MOA: may bind with opioid receptors
in CNS, altering both the perception of
and emotional response to pain

Safe dose: 100 mcg per hour

zinc sulfate Zinca-Pak
220 mg PO daily
Trace element
Nutritional agent
MOA: participates in synthesis and
stabilization of proteins and nucleic
acids in subcellular and membrane
transport systems

Safe dose: 660 mg daily
enoxaparin sodium Lovenox
40 mg SC daily
Low-molecular-weight heparin
derivative
Anticoagulant
MOA: accelerates formation of
antithrombin IIIB-thrombin complex
and deactivates thrombin, preventing
conversion of fibrinogen to fibrin. Has
higher antifactor Xa-antifactor IIa
activity ratio

Safe dose: 40 mg SC once daily for 6-
11 days; up to 14 days can be
tolerated
lorazepam Ativan
0.5 mg PO 3X daily
Benzodiazepine, sedative hypnotic,
antianxiety agent, anticonvulsant,
skeletal muscle relaxant, antiemetic
MOA: inhibits ability to recall events.
Interacts with GANA-benzodiazepine
receptor complex in the brain

Safe dose: up to 10 mg daily

For pain relief

May interact with: CNS
depressants, other opioid
analgesics, diazepam (CV
depression may occur)

Side effects: confusion,
hallucinations, arrhythmias,
bradycardia, dry mouth, urine
retention, respiratory
depression, apnea

To promote healing of wounds

No significant interactions

Side effects: N/V

To prevent DVT, pulmonary
embolism

Side effects: peripheral
edema, CV toxicity,
hypochromic anemia,
thrombocytopenia,
hemorrhage, bleeding compli-
cations, redness/irritation at
injection site

To prevent/reduce anxiety

May interact with other CNS
depressants

Side effects: airway
obstruction, apnea, blurred
vision, confusion, crying,
delirium, depression,
excessive drowsiness,
hypotension, respiratory
depression, hypotonia,
1.Monitor bladder function, respiratory
rate and depth, and O2 saturation
2. Report respirations of <12/minute,
O2 sat of <95%

1.Monitor serum zinc levels. Normal
range is 0.05 0.15 mg/dL

For severe overdose, give protamine
sulfate by slow IV infusion at
concentration of 1% to equal dosage
of enoxaparin injected

1.Monitor platelet count
2. To avoid drug loss do not expel air
bubble from 30- or 40-mg prefilled
syringes
3.Do not massage after SC injection.
Rotate sites among the L and R
anterolateral and the L and R
posterolateral abdominal walls
4.Monitor pt for s/s of bleeding

1.Monitor liver, kidney, and hematapoietic
function periodically

Patient is taking these types of meds
also list in another color or mark
with a highlighter!
Notice that any teaching r/t
applying the fentanyl patch
has not been included -
patient is a quadriplegic and
unable to apply it herself.
Teaching would be directed
at family/caregivers, if
appropriate
pantoprazole sodium Protonix
40 mg PO daily
Proton pump inhibitor, gastric acid
suppressant
MOA: inhibits the activity of the proton
pump by binding to hydrogen-
potassium adenosine triphosphate,
located at secretory surface of the
gastric parietal cells. Suppresses
gastric acid secretion

Safe dose: 40 mg daily x8 weeks
docusate sodium Colace
100 mg PO 2X daily
Emollient laxative
MOA: reduces surface tnsion of
interfacing liquid contents of bowel;
promotes additional liquid into stool,
thus forming a softer mass


ascorbic acid Vitamin C
500 mg PO daily
Water-soluble vitamin
MOA: stimulates collagen formation
and tissue repair; involved in
oxidation-reduction reactions
throughout the body

Safe dose: up to 500 mg daily for
patients with delayed wound healing

levothyroxine Synthroid
125 mcg PO daily
Thyroid hormone replacement
MOA: not fully defined; stimulates
metabolism by accelerating cellular
oxidation

Safe dose: up to 200 mcg daily

vancomycin HCl Vancocin
1 GM IV in NS q 12 hours
Glycopeptides
Antibiotic
MOA: hinders bacterial cell wall
synthesis, damaging bacterial plasma
membrane and making cell more
vulnerable to osmotic pressure

Safe dose: up to 1000 mg q 12 hours
(2000 mg daily)

To treat GERD

Side effects: headache,
insomnia, asthenia, migraine,
anxiety, dizziness, diarrhea,
abd. pain, constipation, urinary
frequency, UTI, back pain,
neck pain, bronchitis,
increased cough

To prevent/relieve constipation

Side effects: mild cramping,
diarrhea

1.Monitor for signs of epigastric or
abdominal pain, and for blood in stool
or emesis
2. Tablet must be swallowed whole and
not crushed, split, or chewed
3.Give with or without food

1.Teach patient about maintaining
adequate fluid and fiber intake

1.Give PO solution directly into mouth or
mix with food
2.Teach patient about dietary sources of
Vitamin C

1.Monitor TSH levels
2.Give drug at the same time each day,
to keep hormone level constant
3.Instruct pt to immediately report chest
pain, palpitations, sweating, or
shortness of breath

IV Administration
Dilute in 200 ml NS
Infuse over 60 minutes
Do not infuse with any other medications

1.Monitor peaks and troughs
2.Monitor site for phlebitis/irritation/
infiltration/extravasation

To promote healing

Side effects: diarrhea, acid
urine, renal calculi

To treat hypothyroidism

Side effects: tachycardia,
palpitations, HTN, dysphagia,

To treat staph infection
(cellulitis of L upper thigh)

Side effects: tinnitus,
ototoxicity, nephrotoxicity,
wheezing, dyspnea, red man
syndrome

Always include instructions for
giving a med intravenously
Generic name not
capitalized
Patients specific
infection.
To treat skin structure infection
(cellulitis of L thigh)

Side effects: vein irritation,
thrombophlebitis, anemia,
thrombocytopenia,
thrombocytopenic purpura,
leukopenia, agranulocytosis

For moderate to severe pain

May interact with: other opioid
analgesics (fentanyl)

Side effects: hypotension,
bradycardia, constipation,
ileus, urine retention,
respiratory depression

Multivitamins are prescribed
for patients who need extra
vitamins, who cannot eat
enough food to obtain the
required vitamins, or who
cannot receive the full benefit
of the vitamins contained in
the food they eat

To treat depression

Side effects: confusion,
tachycardia, dry mouth, taste
perversion, upper respiratory
infection, increased sweating

ampicillin sodium (1GM) and

sulbactam sodium (0.5GM)
Unasyn
1.5 GM IV q 6 hours
Aminopenicillin and beta-lactamase
inhibitor
Antibiotic
MOA: ampicillin inhibits cell-wall
synthesis during microorganism
multiplication; sulbactam inactivates
bacterial beta-lactamase, the enzyme
that inactivates ampicillin and provides
bacterial resistance to it

Safe dose: up to 3GM q 6 hours
(12 GM daily)

oxycodone CR
40 mg PO q 8 hours
Opioid analgesic
MOA: same as fentanyl

Safe dose: up to 80 mg q 12 hours

multivitamin
1 cap PO daily
Nutritional supplement

citalopram hydrobromide Celexa
40 mg PO daily
SSRI
MOA: may enhance serotonergic
activity in CNS by inhibiting neuronal
reuptake of serotonin

IV Administration
Reconstitute with: NS, D5W, or LR
Allow to stand a few minutes to allow
foam to dissipate
Inject over 10-15 minutes or dilute in 50-
100 ml of a compatible dilutent and infuse
over 15-30 minutes
Change site q 48 hours
Do not add or mix with other drugs

1.Monitor rate and depth of respirations; if
<12, report immediately
2.Give with food or milk to prevent GI
upset
3.Assess pain using a pain rating scale
before and after administration

1.Monitor VS regularly for signs of
decreased BP or tachycardia

28
Patient did experience vein
irritation; because of my
med research, I was
prepared for this possibility.
See summary of pt status at
end of day 1.
MedicationOrder Rationaleforuseinthis
patient
NursingCareMeasures

diazepam Valium
1 mg PO q 6 hours prn
Benzodiazepine
Anxiolytic, skeletal muscle relaxant,
anticonvulsant, sedative-hypnotic
MOA: may depress CNS at limbic and
subcortical levels of brain; suppresses
spread of seizure activity produced by
epileptogenic foci in cortex, thalamus,
and limbic system


acetaminophen Tylenol
Non-opioid analgesic
MOA: analgesic effects by blocking
prostaglandins or pain receptor
sensitizers
May relieve fever by acting in
hypothalamic heat regulating center
Relieves pain and fever


oxycodone HCl OxyContin
OR
Opioid analgesic
MOA: same as fentanyl, oxycodone
CR

Safe dose: 5 mg q 6 hours (20 mg/24
hours)
This dose is not safe (pt may have
tolerance)
PRNs

To treat anxiety or muscle
spasms

depressants

Side effects: hangover, ataxia,
psychosis, tremors,
bradycardia, CV collapse,
diplopia, urine retention,
respiratory depression,
desquamation

As needed for discomfort or
fever

Side effects: neutropenia,
leukopenia, thrombocytopenia,
liver damage, hypoglycemia,
jaundice

For moderate to severe pain

depressants

Side effects: hypotension,
bradycardia, constipation,
ileus, urine retention,
respiratory depression

1.Monitor pulse and rate and depth of
Respirations
2.Report pulse <60 or respirations <12

Antidote: acetylcysteine initially 140
mg/kg PO followed by 70 mg/kg PO q 4
hours for 17 doses

1.Carefully monitor all sources of
acetaminophen to ensure that
administration does not exceed 4000 mg
daily

Nursing actions same as for oxycodone
CR
29
PRIORITYDIAGNOSES NURSINGINTERVENTIONS RATIONALES
immobility,pressureover
bonyprominences
Subjective/Objectivedata:
Redness,moisture,broken
skin,openareas,drainage
Assess
1.Site(s)ofskinimpairmentatleastoncedailyforsignsof
infection(colorchanges,redness,warmth,swelling,
exudate,odor)
2.Patientscontinencestatus
3.Nutritionalstatus(weight,calories,protein,CHO,fats,
vitamins,minerals,prealbumin)
Prevent
1.Measuresizeanddepthofwound.Determinethat
impairmentinvolvesskindamageonly.ClassifyasStage
IorII
2.Minimizeexposureofskinimpairmentandotherareasto
moisturefromincontinence,perspiration,orwound
drainage
3.InitiateaPTconsulttoconductariskassessmenttoolto
systematicallyassessimmobilityrelatedriskfactors
4.Avoidpositioningpatientonsiteofimpairment(coccyx)
5.Turnandrepositionq2hours
1.Systematicinspectioncanidentifyimpending
problemsearly
2.Moisturefromincontinencecontributestopressure
ulcerdevelopmentbymaceratingtheskin
3.Optimizingnutritionalintakeisneededtopromote
woundhealing
1.Establishesabaselineforcomparisonwhenevaluating
healing
2.Moisturecontributestopressureulcerdevelopmentby
maceratingtheskin
3.AvalidatedriskassessmenttoolsuchastheNortonor
Bradenscaleshouldbeusedtoidentifypatientsatrisk
forimmobilityrelatedbreakdownandtohelpguidethe
planofpreventionandcare
4.Createspressureandinterfereswithperfusion
5.Alternatessitesofpressurereliefandkeepsthepatient
Citations not required in NUR 51
These are the s/s that you
directly observe or that
are reported by the
patient
6.Transferpatientwithcaretoavoidexternalmechanical
forces(pressure,friction,shear)
7.MaintainHOBatlowestpossibledegreeofelevation
8.Useliftdevices,pillows,foamwedgestoassistpatient
withmovingandpositioning
9.Applywoundgeldaily;packwith1rollofgauzeand
coverwithDSD
10.Avoidmassagingaroundwoundsitesandoverbony
prominences
11.Identifythephaseofwoundhealing(inflammation,
proliferation,maturation)
Evaluate
1.Patientwillregainintegrityofskinsurface
comfortable
6.Preventsskindamage
7.HavingHOBat<30degreesminimizesshearingof
tissuescausedbyslidingdowninbed
8.Tomaintainalternativepositionsandpadbony
prominences
9.Physiciansorder.Promoteshealingandprotects
wound
10.Thiscanresultindeeptissuedamage
11.Accurateunderstandingoftissuestatusprovidesa
basisfordeterminingappropriatetreatments.
Physicians specific
order for dressing
changes
Expected outcome
31
PRIORITYDIAGNOSES NURSINGINTERVENTIONS RATIONALES
wounds
Assess
1.Temperatureqshiftandprn
2.Forredness,warmth,edema,exudates,odor,elevated
temperature
3.Skinformoisture,texture,andturgor
4.Nutritionalstatus(weight,calories,protein,CHO,fats,
vitamins,minerals)
Prevent
1.Monitorlabvalues(WBC,differentials,prealbumin,
serumalbumin,cultures)
2.Washandthoroughlydryskin(pat,dontrub).Take
particularcarewithskinfolds
3.Encourageabalanceddiet.Emphasizeproteins,vitamins
(A,B6,B12,C,E),folicacid,linoleicacid,zinc
4.Give1tabletmultivitaminPOdaily@0800
5.Givezincsulfate220mgPOdaily@0800
6.AdministerVancocin1GMIVq12hours@0600/1800and
Unasyn1.5GMIVq6hours@0200/0800/1400/2000
1.Elevatedtemperatureisasignofinfection
2.Theseareindicationsofinfection Subjective/Objectivedata:
Elevatedtemp.,redness,
warmth,edema,prurulent
drainage,odor,abnormal
labvalues,positivecultures
3.Intactskinisnaturesfirstlineofdefenseagainst
microorganismsenteringthebody

4.Optimizingnutritionalintakeisneededtopromote
woundhealing

1.Labvaluesprovideaglobalviewofpatientsimmune
function

2.Maintaingsuppleskinisbestmethodforkeepingskin
intact

3.Thesenutrientsarerequiredforefficientfunctioningof
theimmunesystem

4.Physiciansorder.Promoteshealing

5.Physiciansorder.Promoteshealing

6.Physiciansorder.Treatsinfection

Physicians specific
med orders, including
dose, route, and times
7.Takemeasurestopreventnosocomialinfections(frequent
handwashing,steriledressingchanges,standard
precautions)
8.Encouragefluidintake,ifnotcontraindicated
Evaluate
1.Patientwillbecomefreeofinfection
2.PatientsWBCcountwillreturntonormalparameters
Assess
1.Calvesandthighsforredness,warmth,edema,venous
dilation;alsocoolness,pallor,edemadistaltoinflammation
2.Pedalpulses
Prevent
1.PerformpassiveROMexercises
2.Encouragedeepbreathing
3.Measurecalvesandthighsdailywhilepatientissupine.
Monitorforincreasedcircumference
7.Hospitalacquiredinfectionsincreasemorbidityand
mortality
8.Fluidintakehelpsthinsecretionsandreplacefluidlost
duringfever

interruptedbloodflow
immobility
1.TheseareindicatorsofDVT
2.Absentordiminishedpedalpulsesindicatearterial
insufficiency
Redness,warmth,edema,
increaseincircumferenceof
calforthigh,absentpedal
pulses,cool/paleextremity
1.Toincreasecirculation,whichwillpromoteperipheral
perfusion
2.Increasesnegativepressureinthelungsandthoraxto
promoteemptyingoflargeveins,thusincreasing
peripheralperfusion

3.ToassessforextremityenlargementcausedbyDVT.
Anincreaseof>2cmin1dayissignificant,aswellascalf
Ackley indicated
both active and
passive ROM
only passive is
listed due to pts
quadriplegia this
makes the
intervention
specific to the pt
Powerlessnessr/tlossof
function
Crying,passivity,
irritability,guilt,
frustration,verbalizationof
havingnocontrol
4.Consultphysicianaboutuseofantiembolismstockings
5.Increasefluidintaketoatleast23L/day,ifnot
contraindicated
6.GiveLovenox40mgSCdaily
Evaluate
1.Patientwillmaintainadequateperipheralperfusionas
evidencedbynormalskincolor,temperature,andpositive
bilateralpedalpulses
Assess
1.Low:expressionsofuncertainty,passivity
2.Moderate:nonparticipationincareordecisionmaking
whenopportunitiesareprovided;resentment,anger,and
guilt;reluctancetoexpresstruefeelings;passivity;
dependenceonothersthatmayresultinirritability;feeling
alienationfromcaregivers;expressionsofdissatisfaction
andfrustrationbecauseofinabilitytoperformprevious
tasks/activities;expressionofdoubtregardingrole
performance;doesnotmonitorprogress;doesnotdefend
selfcarepracticeswhenchallenged;inabilitytoseek
diameter>3cmlargerthantheothercalf
4.CompressionstockingshelppreventDVTin
hospitalizedpatients
5.Toreducehemoconcentration,whichcancontributeto
developmentofDVT
6.Physiciansorder.PreventionofDVT
Itisnecessarytodeterminethelevelofpowerlessness
thepatientisexperiencingsothatthenursecanchoose
appropriateinterventions.
Thispatientexhibitsbehaviorsfromallthreelevels.
informationregardingcare
3.Severe:verbalexpressionofhavingnocontroloverself
care,orinfluenceoversituation,orinfluenceover
outcomes;apathy;depressionregardingphysical
deteriorationthatoccursdespitepatientscompliancewith
regimen
4.Assessmyownphilosophiesofcaretoensurethatcontrol
issuesorlackoffaithinthepatientscapabilitieswillnot
biasmyabilitytointervenesincerelyandeffectively
Prevent
1.Bealertforbehaviorsthatattempttoassertpower,evenif
theyseemconfrontational.Assistpatienttochannelthose
behaviorsinaneffectivemanner
2.Determinethepatientslocusofcontrolrelatedtoher
health
3.Establishatherapeuticrelationship(spendoneonone
timewithher,keepcommitments,provideencouragement,
listenattentively,beempathetic)
4.Allowpatienttoshareherfeelings
5.Encourageparticipationinselfcareandselfmanagement
4.Professionalselfreflectionisanimportantelementin
themaintenanceofanempowermentphilosophy.Such
reflectionhelpsthenursecometotermswiththe
cognitivedissonanceoftryingtoempowerpatients
withinorganizations(healthcaresystem)thatare
inherentlydisempowering
1.Patientislookingforameasureofcontrol.Assisting
hertochannelherenergiesappropriatelyis
empowering.
2.Anexternallocusofcontrolcanleadapatientto
believethatshehasnopoweroverasituation
3.Powerlessnessisheightenedwhenthereisasenseof
distance,violation,ordisconnection
4.Listeningtothepatientreducesherfrustration
5.Themoreapatientparticipatesinherowncare,the
ofillness.Haveherassistinplanningcarewhenever
possible
6.Keepitemsthepatientneeds,wants,andisabletouse
withinreach(tissues,calllight,televisionremotepatient
isabletouseherfingers)
7.Giverealisticandsincerepraiseforaccomplishments
8.Acknowledgesubjectiveconcernsorfears
Evaluate
1.Patientwillstatefeelingsofpowerlessnessandother
feelingsrelatedtopowerlessness
lesspowerlesstheyfeel
6.Wellbeingcanbeaffectedmuchmorebychoices
relatedtoactivitiesofdailyliving.Patientisableto
participateinherowncareifdevicesareaccessible
7.Givingrealisticpraiseassiststhepatientindeveloping
positivefeelingsandenhancesselfconcept
8.Allfeelingsarepersonalandhavemeaningforthe
patient
2.Patientwillparticipateinplanningandimplementing
care,andmakedecisionsregardingcareandtreatment
whenpossible
3.Patientwillverbalizehopeforthefuture
Note the specificity

you would not place
the phone, food, or
drink within reach
because this patient is
unable to move. She is,
however, able to grasp
items and use her
fingers
ChronicSorrowr/t
permanentdisability
Sadness,crying,fear,
verbalizationof
helplessness,hopelessness,
lackofappetite
Assess
1.Forexpressionsofsadness,anger,beingmisunderstood,
confusion,depression,disappointment,emptiness,fear,
frustration,guilt,orselfblame,helplessness,hopelessness,
loneliness,lowselfesteem,beingoverwhelmed
Prevent
1.Identifyproblemswitheatingorsleeping
2.Spendtimewiththepatientanddevelopatrusting
relationship
3.Helpthepatientunderstandthatsorrowmaybeongoing;
notimetableexistsforgrieving,despitepopularthought
1.Feelingssuchastheseareindicatorsofchronicsorrow
1.Bereavedindividualshaveamoderateriskforpoor
nutrition
2.Anempatheticpersonwhotakesthetimetolisten,
offersupportandreassurance,recognizesandfocuses
onfeelings,andappreciatestheuniquenessofeach
individualishelpfultopatientsexperiencingchronic
sorrow
3.Studieshavedemonstratedthatfeelingsofsadness,
anger,frustrationandfearoccurperiodicallythroughout
thelivesofpeopleexperiencingchronicloss(this
womanisgrievingherlossoffunctionandprevious
lifestyle)

4.Evaluatepreviouscopingskills 4.Helpsthenurseunderstandwhathashelpedthe
patientinthepastanddeterminewhethernewcoping
strategiesareneeded

5.Evaluatesupportsystems 5.Helpsthenursetounderstandwhetherthepatienthas
supportorwhetheradditionalresourcesareneeded

Does the pt have
family, friends,
government/social
services?
Specify the patients
loss
6.Identifyavailablecommunityresources,includinggrief
counselorsorsupportgroups
7.Identifywhetherpatientisexperiencingdepression,
suicidalideation,orotheremotionaldisorders.Arrange
forcounselingservicesasappropriate
Evaluate
1.Patientwillexpressappropriatefeelingsofguilt,fear,
anger,orsadness
2.Patientwillidentifyproblemsassociatedwithsorrow
(changesinappetite,insomnia,nightmares,decreased
energy)
3.Patientwillplanforthefutureonedayatatime
6.Supportgroupscanserveasahelpfulmeansto
improveinterpersonalcopingstrategies
7.Counselingwiththerapeuticgoalsettinghasbeen
showntobehelpful
38
WhySuchLongCarePlans?
Youarenotthefirststudenttoaskthatquestion.Muchgrumblingand
complaininggoesoninregardtoBCCcareplans.Whileyoureuplateatnight
allyoucanthinkisThisisridiculous,Theyexpecttoomuchinformation,
Whysomanydetails?DoIreallyneedtoknowthis?andsoon,andsoon,
andsoon.Welcometonursing,theBCCway!
Iadmittoexperiencingawiderangeofnegativefeelingsaboutourcareplans;
Iwentsofarastowonderiftheinstructorsprimaryreasonforrequiringthemto
besodetailedandlengthywastotortureus!Imsureyouvehadoccasionto
feelthesamewayandifyouhavent,youwill.Well,letmeassureyouthat
thesefeelingsareborneoutofsheerfrustration(theyarentreallytryingto
tortureyou).Imetmanynurses,fromseveraldifferentschoolswho,upon
gettingalookatmycareplan,gleefullyinformedmethattheirswerenothing
likethat.Oh,howIenviedthem!Now,notsomuch.
Iamconvincedthatthesecareplansmademe(andwillmakeyou)abetter
nurse.Likeyou,Ioftenbelievedthatsomuchofthedetailedminutiaethatwe
wererequiredtolookupandunderstandwerewayaboveandbeyondwhatwe
neededtoknow.Clottingfactors?Myjobistogivethewarfarinandmonitor
prothrombintime;isntitthephysiciansjobtoworryaboutclottingfactors?
Betablockers,calciumchannelblockers,ACEinhibitors?Theyallcontrolhigh
bloodpressure,right?DoIreallyneedtoknowthedifferencesbetweenthem?
Imtryingtobeanurse,notapharmacist.Detailssuchasthesedrovemeto
heightsoffrustrationandresentmentthatsometimesmademequestionwhether
allthisworkwasworthit.Then,gradually,astrangeandwonderfulthing
begantohappen...Iknewwhatclottingfactorswereandwhichoneswere
targetedbywhatmedications,withouthavingtolookitup.Withoutabook,I
couldtellmypatientwhichclassofantihypertensiveheratenololwas,andhow
thatparticularmedicationworkstolowerherbloodpressure.Inadvertently,
almostwithoutmybeingawareofit,detailssuchasthesewereincorporatedinto
myknowledgebasethroughthetediumofhavingtoresearchthemoverand
overwhilewritingcareplans.Youwillresearchandwriteaboutsurgeries,
medicalconditions,laboratoryvalues,andmedicationssomanytimesyouwill
almostbeabletorecitetheminyoursleep.Asaresultofthis,youwill
eventuallycometoaplacewhereyouareabletosynthesizeallthisinformation
inyourheadandunderstandhowitalltiestogethertoaffectyourpatient.You
arelearningtocriticallythink.Theexhaustivenumberofhoursyouspendon
careplansare,minuteforminute,hoursofinvaluablelearning.Thoughyou
39
maybesittingathome,researchingandwriting,youareundoubtedlygrowing
inyourclinicalpractice.
LetmesaythatIdoubtyouwilleverenjoywritingacareplan.However,the
processwillbecomelesschallengingandtimeconsumingasyouadvance
throughnursingschool.Moreover,youwillfindyourselfontheclinicalunit
caringforyourpatientswithouthavingtoconsultyourcareplaneveryfive
minutes.Seeyourselfpracticingwithconfidence...thatiswhatyourcareplans
arepreparingyoutodo.
40
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
Section Four: Self Evaluations
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
Afteryourclinicalweekisoveritwillbetimetoturnyourattentionto
completingyourselfevaluation.Thisisawritingintensiveexercisethatrequires
youtoreflectonyourclinicalexperienceandhonestlycritiqueyourperformance
asaproviderofcare,managerofcare,andmemberoftheprofession.Itisan
importantcomponentofyourlearningandatoolbywhichtomeasureyour
growthasapractitioner.Yourinstructorwillknowhowwellyouaredoingand
whatyourstrengthsandweaknessesarebyobservingyoueachweekasyou
interactwithpatientsandstaffinclinical;shewantstoknowwhetheryouknow,
andyourselfevaluationisthetoolsheusestodeterminethat.
Aselfevaluation(orselfeval,asitiscommonlycalled)isneverrightor
wrong.Youarenotgradedonit.However,itallowsyourclinicalinstructorto
understandyourlevelofselfawareness,aswellasyourinsightandjudgment,
whichwillbeconsideredasshepreparesyourendofcourseclinicalevaluation.
Asnurses,itisimportantforustoperformselfassessmentssothatweareaware
offeelingsandpotentialprejudicesthatmayaffectourpractice.Itis
unacceptableforapatienttoreceivelessthanoptimumcarebecauseourbeliefs
presentaconflictwhetheritbewiththeirpersonality,race,culture,religion,
sexualorientation,orlifestyle.Examiningourownskills,attitudes,andfeelings
issomethingweneedtodothroughoutthecourseofourcareers,sothatwecan
beconfidentthatweareprovidingthebestcarewepossiblycan.Donotmake
themistakeofthinkingthat,onceyouleavenursingschool,yourselfevaluation
daysareover.Verymuchtothecontrary,theyarejustbeginning.
Iencourageyoutoputyourbesteffortintopreparingthisdocument.Believe
me,Iunderstand,andempathizewith,thetemptationtorushthroughandleave
outimportantobservationsinanefforttojustgetitdone.Youretiredaftertwo
daysofcareplanningandclinical(onlittlesleep,mostlikely)andthelastthing
youfeellikedoingiswritingsomemore.Heck,youdontwanttothink
anymore;youwanttocomehomeafterthatsecondday,lieonthecouch,and
maybeindulgeinsomecomfortfood.Ifyourereallylucky,andthestarsareall
linedupjustperfectly,anap!TrustmewhenItellyouthatthereisntanursing
41
studentalivewhohasntfeltthatway.Heresmyadvice:ifyouhavetheenergy
andmotivation,thinkaboutandwriteyourselfevalrightaway,whilethedetails
ofclinicalarefreshinyourmind.However,ifbeingtiredmightcauseyouto
rushthroughit,donotwriteyourselfevalrightaway.Itsreallythatsimple.In
yoursecondyear,yourselfevalisduethemorningafteryoursecondclinical
day,withoutexception.Puttingitoffforafewhoursrestisnotdetrimental;you
arestillcompletingitbeforeimportantdetailshaveachancetoslipaway.In
yourfirstyear,however,youmayhaveafewdays,perhapseventheentire
weekenddependingonyourclinicalinstructor,beforeitisdue.Thesamerule
appliesastoafewhoursrest.Donot,however,putitoffformorethan24hours.
Waitinglongerthanthatmaycauseyoutoforgetdetailsaboutwhatoccurredin
clinical,nottomentionthatattemptingtowriteitatthelastminuteputsyou
rightwhereyoudontwanttoberushingtogetitdone.Ifyouabsolutelymust
putitoff,doyourselfafavorandatleastjotdownsomenotesforreference
regardingclinicalthatyouwanttoinclude.Iknowitisdifficulttobelievebut
youtrulycanforgetthings,ornotrecallthemasclearly,aslittleasonedayafter
clinical.Youretired,yourestressed,yourereadingtextbooksandhandouts,in
largevolumes,almostconstantly.Itisveryeasyforclinicaldetailstoget
crowdedout.
So,restabitifyouretired,butgetthatselfevaldoneassoonaspossible.
SampleSelfEvaluations
HereIhaveprovidedsamplesoffirstandsecondyearselfevaluations.They
areintendedtoillustrateforyouthecomprehensivenessanddegreeofdetailthat
isexpected.Youwillnoticethattheformatandcontentisabitdifferentforeach,
buttheunderlyingconceptremainsthesameforboth:toevaluate,inwriting,
yourclinicalskills.
42
BCC
SelfEvaluation
NUR11&12
NursesRolesStudentComments InstructorComments
I.ProviderofCare
a.DataCollectionIamfindingthatdatacollectionbecomeseasiereachweek.AsI
growmorefamiliarwiththeKardex,medsheets,andthe
organizationofthechartIamabletolocatetheinformationIneed
morequicklyandefficiently.
b.DataOrganizationIamstillstrugglingtofindawaytoorganizemynotesmore
effectively.Mydataiswellorganizedonmycareplan,butitseems
Iamspendingalotoftimesearchingthroughmynotestoaccessthe
informationIwant,whichisdrawingoutthecareplanwriting
process.Iamhopingthat,withpractice,Iwillbeabletobetter
organizemynotetakingthinkingaheadtothetimewhen,asa
RegisteredNurse,mynoteswillbewhatIwillactuallyworkfromas
Icareforpatients.
c.Planningselected
approachesIplannedselectedapproachesaccordingtomyprioritydiagnosis,
whichwasRiskforInfection.IunderstoodthatIwouldneedto
observemypatientforanysignsofinfectionrelatedtohissurgical
procedureandindwellingsuprapubicandFoleycatheters.In
addition,Iplannedtocompleteathoroughskininspectionwhile
providingAMcare.Theseapproacheswereconsistentwithmy
identifieddiagnosis.
d.ImplementingIimplementedcareasplanned,withtheexceptionofperformingAM
Evaluate howand why you
planned care as you did.
Your instructor knows that you
collected and organized your
data she can see that on your
care plan. Here, provide some
explanation about howthe
process of collecting and
organizing was for you.
care.Thepatientwasscheduledtobedischarged,thereforebathand
linenchangeweredeferredaccordingtohispreference.Ihadthe
opportunitytoperformsomeskillsIhadntplannedforsuchas
discontinuinghisIVandcatheter.Itwasalittledisconcerting,asa
student,tobeputonthespotthiswaybutprovidedexcellent
practiceinlearninghowtoadapttochangesinyourplanofcare.
1.Procedures
(strengths&weaknesses)Ifeltmoreateaseperformingtheheadtotoephysicalassessment.I
amgrowingmoreconfidentwiththisskilleachweekbutrealizethat
thereisroomforimprovement.Wehavebeentaughttobeginour
assessmentatthetopandworkourwaydown,butIfindthatImstill
forgettingsomethingsalongtheway,thenhavingtogobackand
lookatanareathatIvealreadypassed.Thegoodthingaboutthisis
thatIamrememberingthatIforgotitinpreviousweeksI
sometimesdidntrealizethisuntilfillingouttheflowsheet.This
week,Irememberedwithoutneedingareminder.
IthinkIdidwelldiscontinuingthepatientsIVandFoley.Withthe
RNsguidance,Igatheredallthenecessarymaterialsforeach
procedureandremovedtheIV,andthenthepenilecatheter.Itis
quitedifferenttodothisonalivepersonthanitistodointhelab!So
asnottomakemypatientnervousorapprehensive,IactedlikeId
donethisahundredtimesbefore,whichwaschallenging,tosaythe
least.
Ihelpedthepatientdressandpreparefordischarge.Ispentalotof
timetalkingwithhimthroughoutthecourseofmyshift.IfeelI
displayedcompetenceinmostareastoday,notonlyincaringformy
ownpatient,butinassistingmyclassmateswhenneeded.Inotice
thatourabilitytoworkasateamseemstobeevolvingastheweeks
progress.Weassistandconsultoneanotherwithconfidence,more
secureinourclinicalknowledgebaseandpracticethanwewerejust
Describe and discuss any
procedures you performed.
Evaluate your accuracy and
comfort level with honesty.
Were you able to implement care
according to your plan? Why or
why not? Howdid you feel about
working your plan?
4or5weeksago.
MybiggestweaknessismonitoringI&O.Iamnotasdiligentabout
thisasIneedtobe.Imonitorandrecordtheoralintake,butI
neglecttheintakefromIVfluid.Inthisclinical,Ididnotrecordany
output.WhenID/CdthepatientsFoley,theRNtookthebagaway
toemptyit.Iforgottoaskheraboutthevolume,andthenforgotto
checkifithadbeenrecorded.Inordertoimprove,IthinkIllmake
I&Oaprimaryfocusfornextweek.
2.PhysicalsafetyIwasawareofphysicalsafetyatalltimes,bothmyownandthatof
mypatient.
3.BiologicalsafetyIworeglovesforallpatientcontact.Iwascarefultoavoidcross
contaminationbychangingglovesbetweenD/CofthepatientsIV
andD/CofhisFoley.
4.MedicationIfeltfineaboutresearching,retrieving,andadministeringmy
Administration/patientsmeds.Hespoketomeaboutnotwantingtotakehisiron,
Calculationbecauseitmadehimfeelsickandunabletoeat.Iconsideredhis
wishesandspoketohisnurseaboutwithholdingit,andthendidso,
indicatingsuchonhismedsheet.
5.OrganizationofcareIthoughtcarewaswellorganized.Althoughmypatientdidnot
requireclosemonitoringoragreatdealofphysicalcareitwasabusy
day.Mostofushelpedaclassmatecarefortheirpatientinsomeway
whenwewerentcaringforourown.
6.ObservationsThemostimportantobservationImadetodaywashowwellwe
workedasateam.Inretrospect,Irealizedthatweeachwereconfident
aboutandfocusedonourindividualtasksbutfoundthetimetoask
forandgiveassistancewhenneeded.Incomparisontoourearlier
Did you feel you were organized?
Did you find yourself running
around and rushing to get things
done? What could you have done
differently?
Consider your positioning. Did you
protect your back? Was the patients
bed in its lowest position with the side
rails up? Did you practice standard,
contact, and airborne precautions
when necessary?
Be willing to admit to
weaknesses and mistakes.
When you identify a problem
area, discuss what you will
do in an attempt to improve
weeks,goneisthehesitation,fear,anduncertaintyaboutwhatis
requiredofusandhowwearetoproceedwithpatientcare.Post
conferencealsoreflectshowwevelearnedandgrown,asweare
eachabletoprovideacomprehensiveyetsuccinctsummaryofour
patientsconditionsandthedaysevents.
7.Communicationskills/IPR
ChartingWiththeexceptionofI&O,aspreviouslymentioned,Ifeelfairly
confidentwhencharting.Imsurethereisroomforimprovement,
whichwillcomewithpracticeandrepetition.Untilthen,Ijustask
beforechartingifIamuncertainaboutsomething.
ReportingThisisgrowingeasierastheweeksgobyaswell.Iamgettingto
knowthenursesontheunit,andviceversa,andamdevelopinga
routineforconsultingwiththeRNpriortocare,andproviding
updatesthroughouttheshiftasnecessary.Theyaregoodabout
providinguswithinformationaswell,particularlyaboutprocedures
wemaywanttotakepartin.
TeachingItaughtmypatienthow,beforestanding,heneedstosituponthe
edgeofhisbedforafewminutesinordertoavoidbecomingdizzyor
lightheaded.Iprovidedanexplanation,andthenhadhim
demonstrate.
EvaluatingIwasabletoevaluatemypatientsunderstandingbyobservinghis
abilitytofollowmydirections.Hewassuccessfulatassimilating
knowledgeregardingthecontentofmyteaching.
II.ManagerofCare
Seeksassistancefrom
appropriatehealthmembersAtthispointinclinical,Iamseekingoutmyclinicalinstructoror
Did you feel comfortable about
differentiating between what you
need/dont need to report? Was your
nurse receptive? Cooperative?
Was your charting clear, accurate,
and comprehensive while
remaining concise? Howdid you
feel about charting? Howmight
you improve?
Include observations about
anything you found interesting or
were able to learn from
primarynurseforassistancewhenneededandhavenotprogressed
toconsultingmembersofotherdisciplines.
III.MemberofProfession
a.AgencyResourceManualsAlthoughIknowtheirlocation,Ididnotneedtoconsultresource
manualsthisweek
b.AgencyPolicies&
ProceduresIwasawareoftheprocedurestofollowforcarethatIprovided.I
understandthatIneedtoconsultwiththepolicyandprocedure
bindersifatalluncertainaboutthehospitalsprotocols.
c.SelfEvaluationIbelievemyselfevaluationtobehonest,comprehensiveand
specifictothisweeksexperience.
IV.ProgramRequirements
a.AttendancePerfectattendancetodate
b.AssignmentsAllassignmentscompleteandsubmittedontime
c.MathExamPassedonfirstattemptwith95%
d.Participationinpre
andpostconferenceIbelievemyparticipationissatisfactoryandthatIampreparedto
discussandshareanyinformationpertainingtomypatient
assignment
e.AppearanceIaminuniform,whichiscleanandpressed,asrequired.
f.BehaviorAppropriateandconsistent.
g.VeracityBeyondreproach,asisexpected
As a member of the profession, do

you feel you are literate in the
community of nursing? Do you
understand howto find and utilize
resources, such as policy,
procedure, and protocol manuals?
Do you feel that any knowledge you
obtained fromthe manuals helped
you growas a member of the
nursing profession?
Evaluate your self-evaluation
NUR51&52SELFEVALUATIONNAME:DATE:
Pleaseaddressthefollowingareasplusanyothersyouwishorneedtocommenton.UseEnd
OfCourseBehaviorsasguide.AddpaperPRN.
COMMENTS
PROVIDER(datacollection,NCP,worksheet,organization,
assessment,skills,revisions)
Iammostlysatisfiedwithmyperformanceintheseareasthisweek.I
wasabletogatherallpertinentinformationonmypatientand
organizeiteffectively.IreallyfeltlikeIunderstoodthispatient,what
herneedswere,andwhatIneededtodotocareforher.Ifeltreally
comfortableaboutreprioritizingafterinteractingwithherthefirst
day.Thishasbeenoneofmybestclinicalweeksasfarasmygrowth
anddevelopmentasanurse.IfeltlikeIwasabletotakeinand
synthesizenewinformationbasedonmyassessmentswithouthaving
todiginabooktoknowwhattodo.Mycareplan(finally!)feltmore
likeausefultoolratherthanaburden.Ibelieveitwasdetailedand
thorough,andmyrevisionsappropriate,andprovidedmewitha
usefulframeworkfromwhichtoprovidecare.Iambecomingless
attachedtomyworksheet,aswell.AlthoughItakeitoutoccasionally,
forremindersortojotdownnewinformation,Iamlessdependenton
it.Iamawareofcognitivegrowthtakingplace,asIamabletokeep
informationaboutmypatientinmyhead,aswellasassimilatenew
findings,andanalyzehowthingsalltietogether.
Myassessmentsarecarefulandthorough.Asastudent,Iamalways
afraidofthepossibilityofmissingsomething(andprobablywill
continuetobeasanurse).Forexample,Iworriedafterthefirst
clinicaldaythatIhadnotbeenabletolookatmypatientsIVaccess
siteduetothebandagingthatcoveredit.Byday2,whenIcouldsee
thatthebandagehadnotbeenchanged,Igrewveryconcernedabout
thefactthatnoonehadlookedatheraccesssiteforatleast24hours.
Afterfirstgettingpermission,Iremovedthebandagingandwasable
toinspecttheareaanddeterminethatthesitewasnormalandtheIV
patent,muchtomyrelief.Myphilosophyisthatyoucanneverbetoo
careful.
Astoskills,Iwasabletolearnanddosomenewthingssuchas
hanginganIVbagandsettingthepumpandremovinganNGtube.I
wasdefinitelynervous,buttriedmybesttohidethatfromthepatient.
Ineedmorepracticeandimprovementwiththeseskills,naturally,but
nowthatIvedonethematleastoncetheyarenotsointimidating.
COMMUNICATOR(clarity,accuracy,useoftherapeuticinteractive
techniqueswithpts.,staff,charting)
IbelieveIamaneffectivecommunicator.Ilovetalkingwithmy
Howwas data collection? Did you
encounter any difficulties? How
do you feel about your care plan?
Did you struggle with it and, if so,
howand why? Howdid you feel
about working fromyour
worksheet? Do you prefer
working directly fromyour care
plan?
Be specific about
assessments or skills that
you are discussing
patientsandthusfarhavenothaddifficultyestablishingtrusting
relationshipswiththem.Ialwayslistencarefullytowhattheytellme
andtrytoadjustmytherapeuticinteractivetechniquestotheir
individualneeds.
Communicationwithstaffwasclear,beneficial,andbidirectional.I
learnedsomethingsaboutclarityandaccuracyontheflowsheetwith
thehelpofmyprimarynurse.Shetaughtmehowtochart
procedures/treatments(likediscontinuingtheNGtube)andhowto
putanasteriskbythenotationontheflowsheettoindicatethatIhad
writtenanursingnoteaboutit.
TEACHER(assessneed,provideexplanationanddemo)
Italkedwithmypatientabouttheimportanceofturningand
repositioningfrequentlyinordertopreventinfectionandskin
breakdown.AlthoughIassuredherthatIwouldcheckonheroften
(becauseofherdiarrhea),Itoldherthatitwasimportantforhertouse
thecallbuttonifshemovedherbowelswhileIwasntthere,sothat
herskinwouldnotbecomeirritated.Ialsodemonstratedcoughing
anddeepbreathing,butwasmetwithconsiderableresistance,whichI
feelwasduetoherinabilitytofocussecondarytohernauseaand
discomfort.
MANAGER(prioritizingfor2clients,delegating,interactingwithhealth
teammembers)
Ihadonlyaonepatientassignmentthisweek,andsodidnotneedto
prioritize,nordidIdelegateanycare.Ididapproachmyprimary
nurseaboutthepossibility/feasibilityofgettingthepatientoutofbed
andwecollaboratedaboutinitiatingaPTconsult.Ultimately,we
discoveredthattheMDhadalreadyorderedaPTevaluation.
Nonetheless,Imgratifiedthatwewerethinkingalongthesamelines,
andhadadiscussionabouthowtobestapproachthisaspectofthe
patientscare.
MEMBER(legalethicalpractice;IDownstrengths/areastodevelop;seek
learningopportunities)
Ibelievemyselftobeaconscientiousproviderofcare,respectfulof,
andincompliancewithlegalandethicalguidelines.Mystrengththis
weekwasmyabilitytosoothemypatientandcommunicate
unconditionalpositiveregard.Shewasdistressed(andlikely
embarrassed)aboutherexcessivediarrhea.Iwasabletohelpher
relaxandassuredherthatitwasokayifshemadeamess,thatIwould
berighttheretokeephercleanandcomfortable.Infact,Iencouraged
hertojustletitcomeandnottrytoholditback(notthatshecould).
Try to be specific about what
your strengths and
weaknesses were this
particular clinical week. As a
member of the profession,
do you feel you are
improving in your own
practice and/or improving
nursing as a whole?
Even if you do not have
more than one patient,
discuss howyou managed
care on your own, or with
other health teammembers
You are always a teacher!
Dont ever leave this blank or
say that you didnt teach
anything. Even if the patient
wasnt receptive, describe
what, and how, you attempted
to teach
Thismaynotseemlikeabigdealtoanordinary(nonnursing)person,
butasIleanedoverher,heldherhand,andlookedintohereyesasI
spoke,Icouldseeherreliefasheranxietymeltedaway.
Ineedtoworkonconsolidatingmycare.Itendtopacemyselfsothat
Idontendupbeingboredandfeelinguseless.Ireallyneedto
developinthisareabecauseIunderstandthat,asanursewithseveral
patients,Iwillnothavetheluxuryofdoingthis.IamconfidentthatI
willgetplentyofpracticeasmypatientassignmentgrowswiththe
progressionofthesemester.
Iamalwayseagertoobserveorparticipateinnewlearning
opportunities.ThisweekIgottowatchoneofmyclassmatesuse
steriletechniqueandchangeacomplicateddressing.
PROGRAMREQUIREMENTS(punctuality,prepandparticipationin
conference)
Ibelievemyperformanceintheseareaswassatisfactory.Ifeelthat
preconferenceprovidedanexcellentfoundationbeforemeetingthe
patient,andpostwasavaluableforumforevaluationofthedays
objectives.
50
AFTERWORD
Itismysincerehopethatthismanualwashelpfulinguidingyouthroughthe
careplanningandselfevaluationprocess.Itisimportantthatyouknowthat
thesewritingendeavorsareonlythebeginningofwhatwillberequiredofyouin
thenursingprogram.Thewritingassignmentswillgrowmorecomplexasyou
progressthrougheachsemester,requiringahigherlevelofthinking,
organization,andexpression.Learning,earlyon,howtowriteeffectivelywill
provideasolidfoundationforthechallengestocome.
Iencourageyoutotakeadvantageoftheservicesprovidedthroughthecolleges
WritingLab.Theirexcellentstaff,comprisedoffacultymembersandpeertutors,
canhelpyounavigateyourwaythroughanyphaseofthewritingprocess.In
addition,youwillfindwritingsamples,specifictothenursingprogram,thatyou
mayuseasmodelstoassistyouinsuccessfullycompletingyourownwriting
assignments.
If,afterreadingthismanual,youbelievethatIamaneffectivewriterand
successfulstudent,thenIthankyou.However,Iaskyoutorememberthatmuch
ofmysuccesswouldnothavebeenpossiblewithoutsomehelpalongtheway.I
havenotonlyhadtheprivilegeofworkingastutor,buthavehadthebenefitof
beingtutoredaswell,andthathasmadeallthedifference.Therehavebeen
tutorsatthiscollegewhohelpedturnwhatwassimplygoodworkintomybest
work.Iencourageyoutotakefulladvantageofthiscollegesmanyresources
particularlytutoringandwatchyourselfgrow,andbecomethemostsuccessful
studentyoucanbe.
51
References
Ackley,B.J.,&Ladwig,G.B.(2006).Nursingdiagnosishandbook:Aguideto
planningcare.St.Louis:MosbyElsevier.
Carpenito,L.J.(2006).Nursingdiagnosis:Applicationtoclinicalpractice.
Philadelphia:Lippincott,Williams&Wilkins.
Fischbach,F.(2004).Amanualoflaboratoryanddiagnostictests.Philadelphia:
Lippincott,Williams&Wilkins.
Mosbysmedical,nursing,&alliedhealthdictionary(6
th
ed.).(2002).St.Louis:
MosbyElsevier.
Potter,P.A.,&Perry,A.G.(2005).Fundamentalsofnursing(6
th
ed.).St.Louis:
MosbyElsevier.
Springhousenursesdrugguide.(2006).Philadelphia:Lippincott,Williams&
Wilkins.
52
AppendixA
BasicHumanNeedsandRelatedNursingDiagnoses
1.Oxygenation
Ineffectiveairwayclearance
Impairedgasexchange
Ineffectivebreathingpattern
Ineffectivetissueperfusion(specifyperipheral,cardiopulmonary,GI,renal,or
cerebral)
Decreasedcardiacoutput
2.Hydration
Deficientfluidvolume
Fluidvolumeexcess
Riskforimbalancedfluidvolume
3.Nutrition
Impairedswallowing
Selfcaredeficit,feeding
Imbalancednutrition(specifylessthanormorethanbodyrequirements)
Impairedoralmucousmembranes
Nausea
4.InvoluntaryRegulation
Delayedgrowthanddevelopment
Hyperthermia
Hypothermia
Ineffectivethermoregulation
Adultfailuretothrive
5.Elimination
Impairedurinaryelimination
Urinaryincontinence(specifyfunctional,reflex,stress,total,orurge)
Urinaryretention
Constipation
Diarrhea
Bowelincontinence
Selfcaredeficit,toileting
6.Safety/Security
Impairedtissueintegrity
Impairedskinintegrity
Riskforimpairedskinintegrity
Riskforinfection
Ineffectiveprotection
Riskforfalls
Riskforinjury
7.Comfort
Acutepain
Chronicpain
Fear
Anxiety
Chronicsorrow
Disturbedsleeppattern
Ineffectivecoping
8.Activity
Activityintolerance
Impairedtransferability
Impairedphysicalmobility
Impairedbedmobility
Deficientdiversionalactivity
9.Communication
Impairedverbalcommunication
Readinessforenhancedcommunication
10.Sensation
Disturbedsensoryperception(specifyvisual,auditory,kinesthetic,gustatory,
tactile,olfactory)
Acuteconfusion
Chronicconfusion
11.Selfesteem
Disturbedbodyimage
Ineffectivecoping
Disabledfamilycoping
Hopelessness
Powerlessness
Noncompliance
Situationallowselfesteem
Chroniclowselfesteem
Deficientknowledge
Sexualdysfunction
Socialisolation
12.Independence
Ineffectivehealthmaintenance
Deficientknowledge
Healthseekingbehaviors
13.Hygiene
Selfcaredeficit,bathing/hygiene
Selfcaredeficit,dressing/grooming
Impairedskinintegrity
Impairedoralmucousmembranes

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