Registered Nursing Program
\nNURS 260 Medical-Surgical Nursing Across the Lifespan
\nCare Plan<\/p>\n
Objectives:
\n1.\tDemonstrates effective communication with patients across the lifespan through therapeutic communication techniques, active listening, and appropriate terminology. (CLO 3)
\n2.\tDemonstrates confidentiality of patient information. (CLO 4)
\n3.\tElicits patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. (CLO 6)
\n4.\tDemonstrates respect and sensitivity for diverse patients and patient preferences, values, and needs in providing compassionate care, recognizing own values and beliefs. (CLO 6)
\n5.\tRecognizes limits and boundaries of therapeutic patient-centered, nursing care and scope of practice. (CLO 6)
\n6.\tDemonstrates knowledge of basic scientific principles and nursing concepts when applying nursing intervention and standards of care to patients across the lifespan. (CLO 4)<\/p>\n
Student\u2019s Name:_______________________________________________ Date:__________________________
\nPatient Age:__________________ Sex:______________________
\nPatient\u2019s Medical Diagnosis:_____________________________________________________________________
\nSubjective Data\tObjective Data
\nInclude all data that the patient provides you (pain level\/location, patient descriptions, etc.)<\/p>\n
Include all data that you collected or observed (physical assessment, vital signs, urinary output, laboratory values, patient behaviors, etc.)<\/p>\n
Based on your subjective\/objective assessment data, write your NANDA Nursing Diagnosis on the line below (https:\/\/nurseslabs.com\/category\/nursing-care-plans\/nursing-diagnosis\/):
\n____________________________________________________________________________________________________________________<\/p>\n
Complete table below:
\nSMART Goal\tNursing Interventions\tRationale\tEvaluation
\nMust include all components of SMART (specific, measurable, achievable, relevant, timely).<\/p>\n
Example: Patient will maintain an SpO2 level above 90% on room air by 9\/21\/19 at 2300.<\/p>\n
List three (3) interventions that would help the patient to achieve this goal.<\/p>\n
Example: Nurse will encourage ambulation three times daily.\tProvide reasons as to how each of these three (3) interventions will help the patient to achieve this goal (include citations from reputable source).<\/p>\n
Example: Ambulation helps to promote airway clearance and prevent atelectasis.\tState whether the goal was met, not met, or partially met with rationale.<\/p>\n
Example: Goal not met as evidenced by patient requiring 2L of oxygen to sustain an SpO2 level above 90% at 2300 on 9\/21\/19.
\n1.<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.\t1.<\/p>\n
2.<\/p>\n
3.\t1.<\/p>\n
References<\/p>\n
Western Dakota Tech
\nRegistered Nursing Program
\nNURS 260 Medical-Surgical Nursing Across the Lifespan
\nConcept Map\/Care Plan Rubric<\/p>\n
Criteria\/Points\t2.5\t1.25\t0
\nDocumentation of Data\tIncludes medical diagnosis with pathophysiology, medications, diagnostics, treatments, and objective\/subjective assessment.\tDoes not include 1-4 components.\tMissing 5 or more components.
\nRelationships Shown\tPertinent relationships shown between parts of the concept map.\tRelationships are shown but confusing or not relevant.\tRelationships are not shown.
\nEase of Readability\tEasy to follow; clear and useful.\tConfusing to readers; disorganized.\tConcept map does not make sense; irrelevant to client.
\nIntegration of Client\tShows a high level of understanding of the entire client picture.\tShows a moderate level of understanding of the entire client picture.\tDoes not show understanding of the entire client picture.
\nNursing Diagnosis\tNursing diagnosis is a NANDA nursing diagnosis, is written correctly, and contains all components (r\/t, AEB).\tNursing diagnosis is not a NANDA nursing diagnosis.
\nOR
\nNursing diagnosis is a NANDA nursing diagnosis but is not written correctly or is missing components.\tNursing diagnosis is not included.
\nOR
\nPatient identifiers used.
\nSMART Goal\tSMART goal is patient-centered and contains all components (specific, measurable, achievable, relevant, and timely).\tSMART goal is not patient-centered and\/or is missing 1-4 components.\tSMART goal is not included.
\nOR
\nSMART goal is missing all 5 components.
\nOR
\nPatient identifiers used.
\nNursing Interventions\/ Rationale\tAt least three interventions that support the written goal are listed with appropriate rationale. All interventions are nurse-centered.\tOne-two interventions that supports the written goal are listed with appropriate rationale and\/or interventions are not nurse-centered.\tNursing interventions and\/or rationale is not included.
\nOR
\nInterventions do not support the written goal.
\nOR
\nPatient identifiers used.
\nEvaluation\tEvaluation states whether the goal was met, not met, or partially met and rationale was provided.\tEvaluation states whether the goal was met, not met, or partially met but is missing rationale.
\nOR
\nRationale is given but evaluation does not state whether the goal was met, not met, or partially met.
\nOR
\nEvaluation does not address the specific written goal.\tEvaluation is not included.
\nOR
\nPatient identifiers used.
\nConnection\tConcept map and care plan correspond with each other.\tConcept map and care plan are distantly related.\tConcept map and care plan are disconnected.
\nReferences\tReferences listed in APA format for all cited material.\tReferences not listed in APA format.\tReferences not listed.<\/p>\n","protected":false},"excerpt":{"rendered":"
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