Nursing Diagnosis and Goals/Expected OutcomesPhysiologic Mode(Data is clustered into categories as identifiedNUTRITIONStimuliBehaviorPhysiologic ModeSelf Concept ModeRole Function ModeInterdependence ModeNURS 115Fall 2008Recommended Safe DoseClassMOACommon Side EffectsNursing ImplicationsLINCOLN MEMORIAL UNIVERISTYCaylor School of NursingNURS 115Comprehensive Nursing Care Plan Guidelines and Grading CriteriaThe nursing care plan should follow the format, as outlined in the attached sample. A minimum satisfactory grade of 80% on this assignment must be achieved to receive a satisfactory clinical evaluation. If after the 2nd attempt, a student has not scored 80% on the care plan, this will constitute an unsatisfactory grade for the clinical and will result in an “F” for the course.All care plans and reworks must be submitted on the date indicated by the clinical supervisor. In case of an absence, arrangements must be made with the clinical supervisor regarding the late submission. One point per day will be subtracted for the late assignment. All areas must be addressed to receive a grade. All written work MUST BE SUBMITTED in a manila envelope.Assessment:15% Nursing physical assessment 5% Definition of medical diagnosis(es) 5% Developmental comparison (using Erikson) 5% Symptomatology comparison – textbook picture vs. actual assessment findings 5% Lab values – findings compared to normal values and rationale for abnormal values 5% Drug list/cardsNursing Diagnosis and Goals/Expected Outcomes50% Nursing Care Plan Forma. 10% assessment datab. 10% nursing diagnoses with goals/expected outcomes(minimum of 3 nursing diagnoses, with at least two from physiological mode and one from self-concept, role function, or interdependence mode)c. 10% nursing interventions d. 10% scientific rationale for each nursing interventione. 10% evaluation of nursing interventions5% Professional NURSING journal article relating to at least one nursing diagnosis 5% Reference list of at least 5 references and use of APA documentation format 100% total possibleDue Date: Submitted Date: Grade:#1 ________ ____________ _______#2 ________ ____________ _______9/24/08LINCOLN MEMORIAL UNIVERSITYCaylor School of NursingNursing Care Plan Using the Roy Adaptation Model(Sample)Student: ________________ Pt. Initials: ___ Age: _____Date ___________________ Room # ________________Instructor _______________ Diagnosis(es) ____________Physiologic ModeASSESSMENT DATA(Data is clustered into categories asidentified by the RAM)NUTRITIONNURSING DIAGNOSIS(A statement of the healthproblem, etiology & symptoms identifiedafter analysis of assessment data)NURSINGINTERVENTIONS(Each intervention must beindividualized to meet clientneeds. Should not be copieddirectly from text)SCIENTIFICRATIONALE(Rationale for eachnursing intervention withappropriately citedreference)EVALUATIONOF GOALS(Statements as towhether or not eachgoal was met. Why orhow each was met ornot met)Stimuli Behavior Inadequate caloric & nutritive intakeAlways short of time in AMPeer group doesn’t eat lunchParents work; must prepare own mealsDoesn’t understand principles of good nutrition 16 y/o fe; Wt 85 lbHt 5’7”States doesn’t eatbreakfast & onlyhas candy bars @lunchFeels tired Appears drawn & paleAltered Nutrition: Less than body requirements related to poor nutritional intake, poor morning time management, needto prepare own meals, peer group influence, lack of knowledge of principles of goodnutrition AMB underweight, no breakfasts due to no time to prepare own meal, candy lunches, feeling tired, appearing drawn and pale. GOAL STATEMENTS &EXPECTED OUTCOMES[Identify short term goals (STG), usually met in less than aweek & long term goals (LTG), achieved over a long period, 1. Discuss with client possible causes of poor nutritional and poor morning time management.2. Explain the need for adequate consumptionof carbohydrates, fats,protein, vitamins, minerals and fluids.3. Advise how to substitute healthy snacks (fresh fruits, plain popcorn, frozen fruit juice bars, fresh vegetables).4. Consult with a nutritionist to establishappropriate daily 1. Identifying a possible cause enables interventions to eliminate or minimize decreased intake (Carpenito, 590).2. Food nutrients provide energy sources, build tissue, and regulate metabolic processes (Carpenito, 591).3. Increasing healthy snacks reduces the STG:1. Goal met. Has appointment with nutritionist in5 days.2. Goal partiallymet. Has a journal and plans to use itafter nutritionist consultation.3. Goal met. States “less tired when I eat breakfast.”9/24/08weeks or months]STG: The client will:1. attend a nutrition class for teens this week2. eat regular nutritious meals within 1 week, keeping a food diary totrack RDA of nutrients3. feel less tired and have more energy within 1 weekLTG: The client will:1. gain 5 lb within 1 month2. improve color and appearance within 6 months calorie and food needs.pressure for a child to eat a certain amount at meal times (Carpenito, 590).4. Consultation canhelp ensure a diet that provides optimalcaloric and nutrient intake (Carpenito, 590).LTG:1. Not met. Willre-evaluate in1 month2. Not met. Has follow up appointment in 6 months. Roy, C & Andrews, H. (1999). The roy adaptation model. (2nd ed.) Stamford, CT. Appleton & Lange (p. 93-95).9/24/08LINCOLN MEMORIAL UNIVERSITYCaylor School of NursingNursing Care Plan Using the Roy Adaptation ModelStudent: ________________ Pt. Initials: ___ Age: _____Date ___________________ Room # ________________Instructor _______________ Diagnosis(es) ____________Physiologic ModeASSESSMENT DATA NURSING DIAGNOSIS NURSINGINTERVENTIONSSCIENTIFICRATIONALEEVALUATION OFGOALS ORNURSINGINTERVENTIONSStimuli BehaviorGOAL STATEMENTS & EXPECTED OUTCOMES9/24/08LINCOLN MEMORIAL UNIVERSITYCaylor School of NursingNursing Care Plan Using the Roy Adaptation ModelStudent: ________________ Pt. Initials: ___ Age: _____Date ___________________ Room # ________________Instructor _______________ Diagnosis(es) ____________Self Concept ModeASSESSMENT DATA NURSING DIAGNOSIS NURSINGINTERVENTIONSSCIENTIFICRATIONALEEVALUATION OFGOALS ORNURSINGINTERVENTIONSGOAL STATEMENTS & EXPECTED OUTCOMES9/24/08LINCOLN MEMORIAL UNIVERSITYCaylor School of NursingNursing Care Plan Using the Roy Adaptation ModelStudent: ________________ Pt. Initials: ___ Age: _____Date ___________________ Room # ________________Instructor