Nursing Care Plan Template
Name:
John Doe
Class:
NRN 101
Date:
12/12/12
Pt. initial
RB
Age
100
Date of Admit
01/01/01
DOB
07/01/01
Code Status full Allergies
NKDA
Admitting Diagnosis: Pneumonia secondary to a bacterial infection
Nursing Diagnosis: Risk for ineffective tissue perfusion (arterial, venous, and peripheral) STG: Patient will have adequate perfusion AEB Spo2= 95% or greater LTG: Patient will maintain adequate tissue perfusion to vital organs AEB mucous membranes, capillary refill time, pulse quality, urine output and heart rate that are WNL.
For STG/LTG (short term goal/long term goal)
Must be measurable - uses ranges: ____ to ____, greater than or equal to, scale, parameters
Time frame: STG - acute (minutes, hours, days); long term (weeks, months, years)
Assessment
Planning
Rationale
Implementation
Evaluation
Define your problem at hand
These come from the data that you gather during clinical which is why thorough assessment is very important! Spend time with your patients!!
– should include labs, vitals, and objective assessments
How will you solve the problem at hand?
- Monitor, assess, perform, check, obtain, teach, follow protocols/guidelines
Why should we be doing this?
Use a textbook for reference if possible.
Actual interventions
Usually past tense
What care was provided for patient?
How did you gather data to measure against your normal ranges in your outcome criteria?
Frequency - How often did you obtain patient data?
Each goal met/not met: Should read like you actually documented vital signs, assess, care on your patient
What were the results of labs/dx
What was taught/what support measures, comfort used?
WBC 14.2
Keep the client warm and have the client wear socks and shoes or slippers while mobile. Do not apply heat.
Keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissue.
Pt was wearing socks. New pair applied with AM care.
Met. Pulses
John Doe
Class:
NRN 101
Date:
12/12/12
Pt. initial
RB
Age
100
Date of Admit
01/01/01
DOB
07/01/01
Code Status full Allergies
NKDA
Admitting Diagnosis: Pneumonia secondary to a bacterial infection
Nursing Diagnosis: Risk for ineffective tissue perfusion (arterial, venous, and peripheral) STG: Patient will have adequate perfusion AEB Spo2= 95% or greater LTG: Patient will maintain adequate tissue perfusion to vital organs AEB mucous membranes, capillary refill time, pulse quality, urine output and heart rate that are WNL.
For STG/LTG (short term goal/long term goal)
Must be measurable - uses ranges: ____ to ____, greater than or equal to, scale, parameters
Time frame: STG - acute (minutes, hours, days); long term (weeks, months, years)
Assessment
Planning
Rationale
Implementation
Evaluation
Define your problem at hand
These come from the data that you gather during clinical which is why thorough assessment is very important! Spend time with your patients!!
– should include labs, vitals, and objective assessments
How will you solve the problem at hand?
- Monitor, assess, perform, check, obtain, teach, follow protocols/guidelines
Why should we be doing this?
Use a textbook for reference if possible.
Actual interventions
Usually past tense
What care was provided for patient?
How did you gather data to measure against your normal ranges in your outcome criteria?
Frequency - How often did you obtain patient data?
Each goal met/not met: Should read like you actually documented vital signs, assess, care on your patient
What were the results of labs/dx
What was taught/what support measures, comfort used?
WBC 14.2
Keep the client warm and have the client wear socks and shoes or slippers while mobile. Do not apply heat.
Keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissue.
Pt was wearing socks. New pair applied with AM care.
Met. Pulses