LINCOLN MEMORIAL UNIVERISTY Caylor School of Nursing NURS 115 Comprehensive Nursing Care Plan Guidelines and Grading Criteria The 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 cards Nursing Diagnosis and Goals Expected Outcomes 50 Nursing Care Plan Form a 10 assessment data b 10 nursing diagnoses with goals expected outcomes minimum of 3 nursing diagnoses with at least two from physiological mode and one from selfconcept role function or interdependence mode c 10 nursing interventions d 10 scientific rationale for each nursing intervention e 10 evaluation of nursing interventions 5 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 possible 1 Due Date Submitted Date Grade 2 9 24 08 LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing Care Plan Using the Roy Adaptation Model Sample Student Date Instructor Pt Initials Age Room Diagnosis es Physiologic Mode ASSESSMENT DATA Data is clustered into categories as identified by the RAM NUTRITION Stimuli Behavior Inadequate caloric nutritive intake Always short of time in AM Peer group doesn t eat lunch Parents work must prepare own meals Doesn t understand principles of good nutrition 16 y o fe Wt 85 lb Ht 5 7 States doesn t eat breakfast only has candy bars lunch 9 24 08 Feels tired Appears drawn pale NURSING DIAGNOSIS A statement of the health problem etiology symptoms identified after analysis of assessment data Altered Nutrition Less than body requirements related to poor nutritional intake poor morning time management need to prepare own meals peer group influence lack of knowledge of principles of good nutrition 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 a week long term goals LTG achieved over a long period NURSING INTERVENTIONS Each intervention must be individualized to meet client needs Should not be copied directly from text 1 Discuss with client possible causes of poor nutritional and poor morning time management 2 Explain the need for adequate consumption of 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 establish appropriate SCIENTIFIC RATIONALE EVALUATION OF GOALS Rationale for each nursing intervention with appropriately cited reference Statements as to whether or not each goal was met Why or how each was met or not met 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 in 5 days 2 Goal partially met Has a journal and plans to use it after nutritionist consultation 3 Goal met States less tired when I eat weeks or months daily calorie and food needs STG The client will 1 attend a nutrition class for teens this week 2 eat regular nutritious meals within 1 week keeping a food diary to track RDA of nutrients 3 feel less tired and have more energy within 1 week LTG The client will 1 gain 5 lb within 1 month 2 improve color and appearance within 6 months Roy C Andrews H 1999 The roy adaptation model 2nd ed Stamford CT Appleton Lange p 93 95 9 24 08 pressure for a child to eat a certain amount at meal times Carpenito 590 4 Consultation can help ensure a diet that provides optimal caloric and nutrient intake Carpenito 590 breakfast LTG 1 Not met Will reevaluate in 1 month 2 Not met Has follow up appointment in 6 months LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing Care Plan Using the Roy Adaptation Model Student Date Instructor Pt Initials Age Room Diagnosis es Physiologic Mode ASSESSMENT DATA Stimuli NURSING DIAGNOSIS Behavior GOAL STATEMENTS EXPECTED OUTCOMES 9 24 08 NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION OF GOALS OR NURSING INTERVENTIONS LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing Care Plan Using the Roy Adaptation Model Student Date Instructor Pt Initials Age Room Diagnosis es Self Concept Mode ASSESSMENT DATA NURSING DIAGNOSIS GOAL STATEMENTS EXPECTED OUTCOMES 9 24 08 NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION OF GOALS OR NURSING INTERVENTIONS LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing Care Plan Using the Roy Adaptation Model Student Date Instructor Pt Initials Age Room Diagnosis es Role Function Mode ASSESSMENT DATA NURSING DIAGNOSIS GOAL STATEMENTS EXPECTED OUTCOMES 9 24 08 NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION OF GOALS OR NURSING INTERVENTIONS LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing Care Plan Using the Roy Adaptation Model Student Date Instructor Pt Initials Age Room Diagnosis es Interdependence Mode ASSESSMENT DATA NURSING DIAGNOSIS GOAL STATEMENTS EXPECTED OUTCOMES 9 24 08 NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION OF GOALS OR NURSING INTERVENTIONS 8 Lincoln Memorial University Caylor School of Nursing NURS 115 Fall 2008 Student Name Date of Care Facility Clinical Supervisor Name generic brand Dose Route Frequency Recommended Safe Dose 08 13 08 Class MOA Mechanism of Action Reason YOUR patient resident is receiving Common Side Effects Nursing Implications