A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in patient care would be lost.
Medical Diagnosis: Alzheimer’s disease
NursingCare Plan Form
Student Name |
Date |
Patient (initials only) |
Patient Medical Diagnosis |
Nursing Diagnosis (use PES/PE format) |
Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) |
Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) |
Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale
(Provide reason why intervention is indicated / therapeutic; provide references.) |
Outcome Evaluation & Re-planning (Was goal met? How would you revise the plan of care according the patient’s response to current plan?) |
||
1. 2. 3. |
Statement #1 Statement #2 |
1.
2. 3. 1. 2. 3. |
Outcome #1 Outcome #2 |
Sample Nursing Care Plan
Student Name: Sally Jones Date: 1/17/12
Patient (initials only): R. N. Patient Medical Diagnosis: Stroke
Nursing Diagnosis (use PES format): Impaired physical immobility related to motor track dysfunction as evidenced by weakness and lack of coordination
Nursing Interventions
(List at least two nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale
(Provide reason why intervention is indicated/therapeutic; provide references.) |
Outcome Evaluation & Replanning (Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?) |
||
1. +2 weakness on left upper and lower extremity 2. Inability to walk without assistance (patient shuffles when walks and gets confused as to which leg needs to move to propel forward) |
Statement #1: Patient will perform ROM exercises each hour during the shift. Statement #2: Patient will ambulate from bed to door twice by the end of shift. |
1. Educate pt about importance of ROM exercises. Rationale: If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4). 2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises. 3. Consult with physical therapist for strength training and development of a mobility plan 1. Determine amount of assistance needed to get patient out of bed and ambulate. 2. Clear walkway of hazards. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4). 2. Pt needs to be instructed on how to perform ROM exercises, and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5). 3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman, 1997) 1. Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall. Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2). 2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
Outcome #1: Pt partially met goals. He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform. Will continue to with current plan. Outcome #2: Patient exceeded goal: he walked 4 times. Wil modify plan to increase distance (to nurses’ station). |
A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, quality and consistency in patient care would be lost.
Medical Diagnosis: Alzheimer’s disease
Alzheimer’s disease is a progressive disease that destroys memory and other important mental functions. It’s the most common cause of dementia – a group of brain disorders that results in the loss of intellectual and social skills. These changes are severe enough to interfere with day-to-day life. In Alzheimer’s disease, the connections between brain cells and the brain cells themselves degenerate and die, causing a steady decline in memory and mental function.
Medication Preparation Log (MPL)
Student Name_________________________________________________
Clinical Rotation Date__________________________________________
Patient Initials Room # Code Status Allergies |
Diagnosis Relevant Medical/Surgical History |
||||
Drug |
Dose/Range |
Route |
Time |
Reason for RX |
Top 4 Side Effects |
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