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Nursing Care Plan

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by

Arlene Ruddy

on 19 January 2015

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Transcript of Nursing Care Plan

Learning Objectives
Nursing Care Plan Components
Let's Do It!
Nursing Care Plans
Stepping Stones to Success!
After viewing this presentation, the student will -

1. Define each component of the care plan.

2. Synthesize what information is necessary for each component of the care plan.

3. Construct a sample care plan on pain.
Let's review each column
Using the given scenario, complete your care plan with the information and resources you have.
Subjective Data
This is what the patient is telling you, what you hear.
Objective Data
This is what you observe, what you see.
Nursing Diagnosis
This defines the patient problem you have identified through collecting your subjective and objective data.
Problem
diagnosis
objective data
Goals
You need to formulate at least two goals related to the problem you have identified.
"This is the problem my patient is having."
"This is what my patient is telling me."
"This is where I want my patient to be."
REALISTIC - TIMED - MEASURABLE
Interventions
You need to choose at least five interventions
aimed at helping your patient meet their goals.
Rationale
"This is how I am going to get my patient there."
Implemented
This is in reference to your interventions.
Was I able to implement this intervention?
Yes or No
Why am I doing what I am doing?
Evaluation
This is related to your goals as:
Met
Partially Met
Not Met
Be sure to include which interventions worked and how your patient responded to them in relation to meeting their goals.
Well done!
You have now mastered the art of writing a nursing care plan!
It is written:

___________related to
___________as evidenced by
_______________.
You must include your reference for each rationale.
presented by Arlene Ruddy, RN BSN
My "Game" Plan
Subjective Data -
What my patient is telling me.
Objective Data -
What I observe.
Nursing Diagnosis -
This is the problem my patient is having.
Goals -
This is where I want my patient to be.
Interventions -
This is how I am going to get there.
Rationale -
This is why I am doing what I am doing.
Evaluation -
What worked, and what did not?
Scenario



Your patient is a 78 year-old female who is post-op day two total hip replacement. Her Q-pump was just discontinued, and her pain now needs to be managed with medications. You have both IV and PO medications ordered. She had not had a bowel movement since surgery, her bowel sounds are hypoactive. She reports her pain 8/10 on the pain scale and she winces with any movement. “My hip really hurts now, I am afraid to even move.” Her blood pressure is 156/90, her heart rate is 98.

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