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Roman3$Arial5Symbol?4Courier New;WingdingsGGoudy Old Style9$FreeSansBhTU9f9f00 COMPREHENSIVE NURSING CARE PLAN WWCCWWCC@@Gy@Jky՜.+,D՜.+,\M 0f8Caolan80 23 &,____L `dkkwnbpzkpa ilvjVk Comprehensive Nursing Care Plan Grading Criteria (See attached page for guideline descriptions) ContentPoints PossiblePoints Achieved Format 3Client Profile 2Client Health History 3Student Nursing Assessment 4Pathophysiology 4Diagnostic Tests 4Medications 4Data Analysis 2Plan of Care Diagnosis Expected Outcomes Implementations/Interventions Rationale Evaluation r/t Expected Outcomes 3 3 3 2 3 Total Possible40  DUE DATES ClarkstonWalla WallaMarch 5March 12 Comprehensive Nursing Care Plan Criteria Description Format This is a formal paper and should be word processed with proper spelling, grammar and terminology Present in a highly organized format with headings, bullets, bolding, columns, etc APA 5th edition cover sheet in-text citations running header reference page (minimum of 3 current professional references) Client Profile Client data Current status Client Health History Using agency form, actually admit a client The student must notify the instructor when admitting a client The assessment procedure must be supervised by a Registered Nurse Attach a blank, agency admission form as an appendix Based on data obtained from the agency admission history form, present client s health history in an organized manner using narrative format Student Nursing Assessment Complete assessment written in narrative format, with subject headings (as in a client legal chart) Subjective Data/Complaints Neurological Cardiovascular Respiratory GI GU Musculoskeletal (include Functional Status: 0=self care, 1=requires use of equipment or devices, 2=requires assistance or supervision from another individual, 3=dependent, does not participate) Integumentary (include condition of any invasive site(s), incisions) Pathophysiology Primary (admitting) diagnosis Etiology of condition Textbook symptoms Client admitting symptoms Pathophysiology of disease process (written in your own words) Diagnostic Tests Pertinent lab and diagnostic test results (minimum of 3-4 for full points) Date of test with normal values in parentheses Client specific rationale for pertinent test results Expected assessment findings or follow-up measures needed Additional diagnostic tests you would like to have seen, with rationale Comprehensive Nursing Care Plan Criteria Description (cont.) Medications All scheduled medications and pertinent PRN s (minimum of 3-4 for full points) Trade and (generic) names Client specific rationale for medication (why was this medication ordered for this particular client) Mechanism of action of medication Dose, Route, Time, Frequency Pertinent associated diagnostic tests Common side effects Side effects observed Pertinent nursing implications of drug administration Additional medications you would expect to have seen, with rationale Data Analysis (Gordon s Functional Health Patterns  refer to Cox Care Plan book) Analyze and synthesize all data gathered (history, client profile, nursing assessment, pathophysiology, diagnostics, medications) Health Perception-Health Management Nutritional-Metabolic Elimination Activity-Exercise Sleep-Rest Cognitive-Perceptual Self-Perceptual Role-Relationship Sexuality-Reproduction Coping-Stress Tolerance Value-Belief Developmental Stage (include rationale) Plan of Care Derive plan of care from data analysis Identify and prioritize (3) client specific nursing diagnoses (one must be related to a teaching need) Identify (1) one expected outcome for EACH nursing dx. (client centered, timed, measurable, realistic, concise) Identify (3) nursing interventions with supporting rationale for each expected outcome (only one per expected outcome may be r/t assessment or monitoring) Evaluate client response to interventions in relationship to expected outcome Suggest modifications for expected outcome(s) and interventions as appropriate Comprehensive Nursing Care Plan Client Profile Client Initials Age Gender Date(s) of Care Allergies Date of Admission Code Status Height Weight on Admission Admission VS Admitting Dx Current Surgery with date Pertinent Hx Current Status VS this shift Activity Level Diet Current Weight Location of IV Site(s) IV Solution(s) and Rates PCA/Epidural (drug, concentration, dosage) Support Tube(s) and Location(s) Intake this Shift (differentiate route(s)) Intake last 24 hours (differentiate route(s)) Output this Shift (differentiate route(s)) Output last 24 hours (differentiate route(s)) Client Health History (From agency admission form) Student Nursing Assessment Subjective Data Neurological Cardiovascular Respiratory GI GU Musculoskeletal (include Functional Status) Integument (include condition of any invasive site(s), incisions) Pathophysiology Pertinent Labs & Diagnostic Testing Lab/Diagnostic Findings include date of test (normal values)Client Specific Rationale for Pertinent Test ResultsExpected Assessment FindingsFollow-up measures needed and/or additional diagnostic tests expected  Medications Medications (Trade & Generic)Client Specific Rationale/ Mechanism of ActionDose Route Time FrequencyPertinent Associated Diagnostic TestsCommon Side Effects/ Observed Side Effects Pertinent Nursing Implications/ Additional Medications Expected Data Analysis Gordon s Functional Health Patterns Health Perception-Health Management Nutritional-Metabolic Elimination Activity-Exercise Sleep-Rest Cognitive-Perceptual Self-Perceptual Role-Relationship Sexuality-Reproduction Coping-Stress Tolerance Value-Belief Developmental Stage (Erickson s) Plan Of Care Nursing Dx #1Expected Outcome Implementation RationaleEvaluation r/t Expected Outcome Suggested Modifications Nursing Dx #2Expected Outcome Implementation RationaleEvaluation r/t Expected Outcome Suggested Modifications Nursing Dx #3Expected Outcome Implementation RationaleEvaluation r/t Expected Outcome Suggested Modifications  @bf   & * , 0 2 N R T X Z   $ & < @ B F H b f h l n  P T V Z ^ b f Ѹѡ-B*phCJ5fHq aJOJQJ0B*phCJ6fHq aJ]OJQJ*B*phCJfHq aJOJQJ0:B*phCJ5fHq aJOJQJ?f j l n    D n r ~ B  Db48bu-B*phH*CJfHq aJOJQJ-B*phCJ>*fHq aJOJQJ0:B*phCJ5fHq aJOJQJ-B*phCJfHq aJ\OJQJ-B*phCJ5fHq aJOJQJ*B*phCJfHq aJOJQJ)6$>Bv>vZDpFJj`>TXnBR,"&Ѻѡъ-B*phCJfHq aJ\OJQJ0:B*phCJ5fHq aJOJQJ-B*phCJ5fHq aJOJQJ*B*phCJfHq aJOJQJ0B*phCJ6fHq aJ]OJQJ6 @ X | !.!^!x!!!!2"##%l%%P&T&&&&&&&''b'f'''''( ("(&(((*(ꠉo3:B*phCJ>*5fHq aJOJQJ-B*phCJ5fHq aJOJQJ-:B*phCJfHq aJOJQJ6:;B*phCJ5fHq aJ\OJQJ-B*phCJ>*fHq aJOJQJ*B*phCJfHq aJOJQJ**(F(J(d(h(j(((()) )")v)z)|)))))t*x**+.+0+\++++++++++++,,,,,,:,>,@,B,D,F,\,`,b,d,f,ккк6B*phCJ65fHq aJ]\OJQJ-:B*phCJfHq aJOJQJ*B*phCJfHq aJOJQJ-B*phCJ5fHq aJOJQJ0:B*phCJ5fHq aJOJQJ5f,h,l,p,r,t,v,x,|,,,,,,,,,,,,,-l-p-r-t-v-x-z-|-~-------.F.f.. ////////////////////////軻-:B*phCJfHq aJOJQJ*B*phCJfHq aJOJQJ-B*phCJfHq aJ\OJQJ-B*phCJ5fHq aJOJQJ@//////////////////////////////000000"0\000000:111222222 2"2$2&2(2*2,2.20222426282:2<2>2@2B2D2F2H2J2L2N2P2R2T2V2X2Z2\2^2-:B*phCJfHq aJOJQJ*B*phCJfHq aJOJQJS^2`2b2d2f2h2j2l2n2p2r2t2v2x2z2|2~2222222224383:3<3f3j3l3n33333333333333344 4$4&4(4J4N4P4R4~4444444444445 585T5v5z5-B*phCJ5fHq aJOJQJ-:B*phCJfHq aJOJQJ*B*phCJfHq aJOJQJJz5|5~5555555555556666 686<6>6@6B6D6F6H6J6d666666666666666677777H7L7N7P7R7T7V7X7Z7t7777777777777777 8$8&8(8*8X8\8^8`8b8d8f8*B*phCJfHq aJOJQJUBdf  Zf$$IfF!1" p44l44l4f4 $Ifdh$a$ $If & Fdhdhdh$a$dh$a$ & Fdh & Fdh  ( * . 0 2 P R V X k^S $IfdhG$ $If & F dhf$$IfF!1" p44l44l4f4 $IfdhG$ $Ifdh$a$ $Ifdh $If & F dh X Z ti $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhh$$IfF!1" p44l44l4f4 ti $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhh$$IfF!1" p44l44l4f4 vk $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhf$$IfF!1" p44l44l4f4   " $ vk $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhf$$IfF!1" p44l44l4f4$ & > @ D F vk $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhf$$IfF!1" p44l44l4f4F H d f j l ti $IfdhG$ $Ifdh$a$ $Ifdh $If & F dhh$$IfF!1" p44l44l4f4l n t]F$If & Fdh ^]`$If & Fdh ^]`$If & Fdh ^]` $If & F dhf$$IfF!1" p44l44l4f4  R T X \ ` d h j l $Ifdh !G$ $Ifdh$a$ $Ifdh$a$G$$If & Fdh ^]`$If & F dh ^]` l n x $IfdhG$ $Ifdh$a$ $Ifdhf$$IfF!1" p44l44l4f4 r $If & Fdh $Ifdh$a$ & Fdhdhf$$IfF!1" p44l44l4f4   OG?dh$a$dh$a$R$$If0y  p44l44l4f4 $Ifdh$a$P$$If0y  p44l44l4f4  F p r D "Fd68dh  & Fdh ! 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