Care Plan Cheat Sheet-2 PDF

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NURSING CARE PLAN CHEAT SHEET NURSING DIAGNOSIS

-Based on assessment findings

GOAL/ EXPECTED OUTCOMES

Don’t use goals from Nursing Diagnosis textbook!

INTERVENTIONS

What actions will nurse take to achieve goal?

-Review definition and defining characteristics in Nursing Diagnosis textbook to see if appropriate.

Fundamentals & Nursing Diagnosis textbooks are good Instead, ‘flip’ the problem by restating the problem as sources for interventions. better (improved) or less of Need to think critically when it or none of it. deciding which ones you will -Include r/t etiology (What Goal is pt focused. list on this pt’s care plan. factors are causing or contributing to the Interventions are nurse Include time frame (Can problem?) or risk factors be either long or short term focused (these are actions for nsg dx. nurse will take) goal, don’t have to have both) -R/t factor cannot be a - Must be individualized & medical dx, diagnostic realistic (can’t ambulate an Pt will have less pain by test or s & symptoms. immobile pt, If nsg dx is r/t to end of shift AEB… nutrition or fluids, include Pt will have no pain in one - AEB symptoms foods & beverages pt likes) week AEB… Pt will have improved gas ASSESSMENT DATA Interventions need to be: exchange by Wed at 3pm (Subjective & - specific (walk 50 ft, not AEB… Objective) walk more; administer Ampicillin, notadminister Goal must be realistic & Subjective: list antibiotic), appropriate for client. subjective data that -includes a time frame or supports diagnosi frequency (q 2 hr, or daily) Expected outcome tell us Objective: list related how we know goal is objective data - relate to THIS goal/problem achieved. They must be Only list assessment measurable & data that we know about observable. No set number of this problem for this pt, interventions is expected. 1not ALL assessment data Usually 2-4 expected 2 is too few tho! Probably at you have outcomes are enough. least 4- 5. Include interventions that

RATIONALE WITH REFERENCE

State how this intervention will help reach the goal Textbooks are good sources for this. Paraphrase (put in your own words). Whether paraphrased or a direct quote, each rationale for each intervention must have its source listed after it & in this format: (Ackley & Ladwig, 2017, p. 123)

EVALUATION

Did all the expected outcomes (AEB) occur? If so, then Goal met AEB … comment on each outcome. Did none of them occur? Then Goal not met AEB… Did some of them occur? Then Goal partially met AEB…

Each expected outcome is listed separately. (not lungs clear and RR...