appendix a care plan - howard · pdf filedaily plan of care nursing care plan segments done on...

APPENDIX A CARE PLAN

INSTRUCTIONS FOR CARE PLAN

SPRING SEMESTER

These instructions pertain to our 3 clinical day/week rotation. For the first 3 weeks, there will only be 2 clinical days/week. Therefore, areas designated in these instructions to be completed on Wednesday at 0640, will be due on Thursday at 0640. Once the 3 clinical day/week rotation starts, please note that other components of the care plan will be due on Wednesday at 0640 instead of Thursday at 0640. Be aware of what is due on what day. Points will be deducted if your paperwork is not complete on the appropriate day.

This care plan format will be used only for the medical-surgical patient care rotations. The Care Plan must be contained in a folder, using black ink only. A weekly clinical progress sheet and grade sheet must be in the folder Tuesday morning at 0640. If this sheet is not included, there will be five points deducted from the grade for each missing page.

I. Data Collection. Due Tuesday morning at 0640.

II. Dr’s. Orders. Due Tuesday morning at 0640 These are current doctor’s orders. It should come from the Kardex, computerized information sheets or doctor orders sheet in the chart. Include ALL current scheduled medications given on the day shift (8hr). If the medication is on the master drug sheets, include the classification and page number in the area on the right under that section. Include the date the order was written. Add and update new doctor’s orders as they are written. III. Medical Diagnosis. Due Tuesday at 0640 . Obtain from Med-Surg. book (Timby & Smith). References and page numbers are required. 1. Brief definition 2. Signs and symptoms (textbook and patient) 3. Nursing care IV. Medication Sheet Due Tuesday at 0640 1. Write out only the medications specific to your client that are scheduled to be given in

the 8 hr. shift and are not on the master medication list. 2. Use Drug Book as needed. 3. Update daily as new medication orders are obtained

V. Plan of Care. Due Tuesday at 0640 Using the data collected, the student will develop a list of what he/she plans to do for the client. This data will come from the doctor’s orders, medications and their side effects, signs and symptoms of the medical diagnosis, and the nursing care for the medical diagnoses. Please start each entry on a new line and number. All of the following components will be in the Plan of Care. (Day 1) plus whatever needs to be added. V/S, assessment, AM care and linen change first line. Serving Doctor-ordered diet Activity Safety IV site and IV I & O Tubes Side effects of medications specific to the client Lab tests and x-rays Nursing care for medical diagnoses or surgical procedure Treatments Psychosocial (specific to the patient) Teaching Documentation Update the Plan of care for Wednesday and Thursday by 0640: Do not rewrite the above information written from Tuesday. Write a statement regarding which elements from Tuesday’s list, by number, you are keeping and add new numbers for added care that may apply for the next clinical day. VI. Lab & Diagnostic Test Completed lab sheet of abnormal lab or test results due Wednesday morning at 0640. VII. Nursing Notes – primary client only The assessment and daily care will be documented on the flow sheet. The charting will be done in PIE format using the problems from your prioritized diagnoses list. The assessment and charting will be done for each day of care. VIII. Prioritized Nursing Diagnoses List due Wednesday morning at 0640.

Using your textbooks and the Maslow prioritized NANDA diagnoses list from last semester, develop a list of nursing diagnoses that pertain to your patient. Write the list of actual nursing diagnoses first with the R/T and AEB, then a list of risk diagnoses. (Exactly like you wrote it last semester)

IX. Nursing Process: Sections A, B & C will be completed by 0640 Thursday morning. Section D will be completed by 0800 Friday morning. 3 Physical Nursing Diagnoses – Due Thursday at 0640 2 Psychosocial Nursing Diagnoses – Due Thursday at 0640 The nursing diagnoses will be written in the correct format, be prioritized according to Maslow and all 3 cannot come from the same Maslow section. ie: if there are 3 “oxygen” diagnoses, only the first one by priority should be written up. They should be “actual” diagnoses. “Risk” diagnoses should not be written up on the landscape pages. The outcome statement will be specific, realistic, measurable, timed and pertain to the AEB from that diagnosis. There are client outcomes written for each nursing diagnosis in the diagnosis book and they are a good start, but you need to adapt one of them to fit what is happening with your client. There will be 2 interventions and 2 rationales for each nursing diagnosis. There are many to choose from, but attempt to use “common sense” –“bedside nursing care” interventions. Also look at the Dr’s orders. The interventions chosen must relate to the outcome. The evaluation statement: First circle “met” or “unmet” in the box. In other words, did the client do what you wanted them to do in the outcome statement? You evaluate the client’s response to your care and decide if the outcome was met or unmet. Write a brief statement to explain why the outcome was met or unmet. OTHER INSTRUCTIONS: The nursing diagnoses “Self-care deficit, bathing/hygiene or Self-care deficit, dressing/grooming” cannot be written as one of the psychosocial diagnosis on the “landscape” page. If you are unable to find a second psychosocial diagnosis from another box, page your instructor for further guidance. You must have your instructor’s approval to use 2 diagnoses from the same box. This care plan must be updated DAILY in blue ink. Five points per page will be deducted for using incorrect , blank or having missing pages. Five points per page will be deducted if a weekly clinical progress sheet and evaluation sheet is not with care plan on Tuesday morning. An entire Nursing Care Plan must be completed on your first client, as long as you have worked with them a sufficient amount of time (at least until noon and you have obtained your data), even if he/she is discharged. Check with your instructor if you have questions. For your second client, and any subsequent clients, complete only the first 2 pages, med sheet and plan of care. (Areas I, II, III, IV and V). Attach the second client paperwork and any other client paperwork to the back of the completed care plan.

There will be 2 graded care plans in the spring semester in VNSG 2461. The areas due each morning will be graded on a daily basis. You must maintain an average of 78 or above with your care plan average and 78 or above in your math exam average. When totaled, the math exam average, the care plan average and the clinical evaluation points must equal 78 or greater to pass the course. If you rewrite a page, please hand in the original page with the revised one. *Do not discard any original pages, especially those that an instructor has written on.*

*WEEKLY PROGRESS SHEET

SAN ANGELO CAMPUS VNSG 2461 SPRING 2011

DATE: STUDENT: LOCATION: INSTRUCTOR

EVALUATION STUDENT

COMMENTS (after instructor’s comments)

Preparation for clinical Dress, hygiene, supplies Weekly care plan Medication sheets Daily plan of care

Nursing Care Plan Segments done on time Maslow list Landscape pages Documentation Assessment Interventions Evaluations Facility documentation

Medications Knowledge of drugs Calculation and administration of drugs Documentation

Clinical Skills Performance Communication: with client, staff and instructors Safety Confidentiality Professional conduct Follows policies and procedures of nursing program and facilities; cost containment (DELC-101)

Clinical point tool: ________________

*This page will be attached to the weekly care plan by Tuesday at 0640. Failure to do so will result in 5 points being taken off the weekly care plan grade. Instructor signature: _____________________________________________ Date I have reviewed the above comments written by the instructor. (Sign after reading comments) Student signature: ______________________________________________ Date

Name:_________________________________________Date______________

Criteria for Evaluation of Weekly Care Plan

I. Demographic Data………………………………………………………………………………(1)_________

II. Doctors Orders (5) (Must be updated daily)

A. Diet & Rationale ................................................................................ (1)__________ B. Activity Level ..................................................................................... (1)__________ C. Medications ...................................................................................... (1)__________ D. Treatments ....................................................................................... (1)__________ E. Lab & Test ............................................................................... (1)__________

III. Medical Diagnosis Information .................................................................... (5)__________

IV. Medication Sheet (includes master sheet & client specific drug sheet ....... (5)__________

V. Plan of Care (Must be updated daily)

Must contain: V/S, data for early assessment, diet, S/S of medical diagnosis, treatments, lab & diagnostic test, and bedside nursing care ............................................................... ….(15)_________

VI. Lab & Diagnostic .................................................................................... …. (5)_________

VII. Nurse’s assessment and notes

A. Assessments and Flow sheets …………………………………………....(3)_________ B. Daily PIE charting …………………………………………………………..(6)_________

VIII. Prioritized Nursing Diagnoses List ………………………………………..(5)_________

IX. Nursing Process

A. Nursing diagnoses……………………………………………………………(15)_________ B. Outcome statements…………………………………………………………(10)_________ C. Interventions…………………………………………………………………..(20)_________ D. Evaluations……………………………………………………………………. (5)_________ Total……………………………………………………………………………………… (100)________ Five points per page will be deducted from your grade for incorrect pages, blank or missing pages. Five points will be deducted from your grade if a weekly clinical progress sheet or the grade sheet is not with the care plan on Tuesday morning.

HOWARD COLLEGE VN PROGRAM NURSING CARE PLAN SPRING

Due Tuesday, 6:40am Attach weekly progress sheet and clinical evaluation sheet

I. Name Allergies: Medical Diagnosis:

Cl. Initials : Ht. Wt Medical Hx: 1. Rm# Age: Sex: 2. Date of Admission Surg. Procedure/date: Date of Care: Instructor

II. Doctor’s Orders (Must be updated daily or indicate no new orders) (DLEC-3) Date Diet & Rationale orders written Activity level Medications to include name, dose, route, frequency

Classification. MDS pg. #

Treatments Diagnostic tests

(Due Tuesday AM) 0640

III. Medical diagnosis definition and nursing care for this medical diagnosis, with reference and page numbers. 1. Medical diagnosis definition: Textbook S& S: Client S&S: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Nursing Care: _____________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2. Medical diagnosis definition: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Textbook S&S: Client S&S: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Nursing Care: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

IV. HOWARD COLLEGE VOCATIONAL NURSING PROGRAM DRUG SHEET

NAME: ________________________________ Medication generic (trade)

Dose, Route, Freq

Classification Therapeutic Actions

2-3 Major Adverse Effects, Any Contraindications

Nursing Implications

V. DAILY PLAN OF CARE

DATE: Day 1: Due Tuesday AM 0640 Day 2: Due Wednesday AM 0640 Day 3: Due Thursday AM 0640

VII. INSTRUCTIONS FOR THE DIAGNOSTIC TEST FORM

DATE:

This is the date the test was done

TEST NAME & ABBREVIATION:

Write the test name and abbreviation

SOURCE: Source refers to the portion of the body, which the test

specimen was taken. Example: blood, urine, spinal fluid, would culture, etc.

NORMAL VALUES: Write in normal values for your client’s age and sex. This is

obtained from the book or from the client’s lab sheet OR The arrows indicate that your client’s values are above or

below normal. CLINCIAL SIGNIFICANCE OF ABNORMAL LEVEL;

On abnormal values, wrote the reason the value is significant to the client’s diagnosis.

You may put more than one test on a sheet but skip a line between each. Write legibly. Remember this includes all diagnostic tests such as x-ray, cystoscopy, etc. Each week do lab sheet on the abnormal results pertaining to your client. When a CBC is ordered only the following areas – WBC,RBC,Hgb,Hct. and Platelets need to be included. If there are duplicate test results, eg. H&H daily, include the client’s previous values along with their current values.

VI. LAB VALUE/DIAGNOSTIC TESTS DUE SECOND DAY OF CLINICALS AT 0640 DATE TEST NAME &

ABBREVIATION SOURCE NORMAL

VALUES CLIENT VALUES

↑ OR ↓

CLINICAL SIGNIFICANCE OF THE ABNORMAL LEVEL TO THE CLIENT

VII PIE CHARTING DATE TIME __________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII Prioritized Nursing Diagnoses List: Write the nursing diagnoses in order of Maslow as written on the Nanda Diagnoses List. Write the “actual” diagnoses, then the “risk” diagnoses. Complete all the columns. Choose only from the “actual” list for your landscape pages. Use the back of the page if you run out of room. Number Diagnosis Name Related to As evidenced by Actual 1 2 3 4 5 6 7 8 9 10 11 12 Risk 1 2 3 4 5 6

IX. Columns A, B & C Due Thursday 0640 Column D Due Friday 0800 A. Nursing Diagnoses: 3 physical (3 pts. each)

B. Outcome Statement: 1 per diagnosis (2 pts. each)

C. Nursing Interventions with Rationales: (4 pts. /box)

D. Evaluation of Outcome (1 pt. each)

1. Dx. R/T AEB

1. 2.

Met Unmet Reason why met or unmet:

2. Dx R/T AEB

1. 2.


3. Dx R/T AEB

1. 2.


Columns A, B & C Due Thursday 0640 Column D Due Friday 0800

A. Nursing Diagnoses: 2 psychosocial (3 pts. each)

B. Outcome Statement: 1 per diagnosis (2 pts. each)

C. Nursing Interventions with Rationales: (4 pts. /box)

D. Evaluation of Outcome (1 pt. each)

4. Dx. R/T AEB

1. 2.


5. Dx R/T AEB

1. 2.


appendix a care plan - howard · pdf filedaily plan of care nursing care plan segments done on...

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