TheNursingStudentsPracticalGuide

toWritingCarePlans

ByLuanneBegin



PREFACE

Congratulationsforchoosingnursingasyourcareer!Thenursingprogramhere
atBristolCommunityCollegewillprovideyouwiththeacademicknowledge
andclinicalskillsyouneedtopasstheNCLEX,obtainyourlicense,andbegin
workingasaregisterednurse.Youwillfacemanychallengesoverthenexttwo
yearswhichwillrequireyoutoworkdiligentlyandconscientiouslyinorderto
meettheprogramobjectivesandachieveyourgoals.Youwillbeexpectedto
consistentlystrivefor,reach,andthenexceedyourpersonalbestasyouprepare
toentertheprofessionofnursing.TrustmewhenItellyouthatitcanbedone!

AsarecentgraduateofthenursingprogramIunderstand,fromastudentspoint
ofview,theuniquestrugglesyouarefacing.Icanrememberbeingexactly
whereyouare...intimidatedandoverwhelmedbythedauntingtaskofwriting
theperfectcareplan;or,ifnotperfect,atleastgoodenoughtoearnthatcoveted
andallimportantsatisfactoryfrommyclinicalinstructor.IoftenwishedIhad
anexample,ormodel,thatIcouldfollowwhichwouldassistmeinnavigating
mywaythroughthewritingrequirementsofthiscurriculum.Myfellow
studentsandIoftenremarkedonhowmucheasieritwouldbetowriteacare
planifonlywehadoneinfrontofustolookat!AsalongtimetutoratBristol
CommunityCollege,Ihavealwaysbeenpassionateabouthelpingother
students,andsoastheendofnursingschoolapproached,Idecidedtocreatethis
manualinthehopethatitwouldgiveincomingstudentsthekindofmodelmy
classmatesandIalwayswishedwedhad.

Thismanualhasbeendesignedtoassistyouinmeetingthewritingrequirements
ofthenursingprogram.Itisimportanttounderstandthattheclinical
componentofthiscurriculumisnotlimitedtosimplymasteringtechnicalskills
andprovidingdirectpatientcare;itrequiresyoutocriticallythink,andthen
writeabout,allaspectsofthatcare.Beforeyouevermeetyourpatient,youwill
beaskedtoconductresearch,collectdata,andpresent,inwriting,a
comprehensiveplandetailingyourunderstandingofthatpatient,includinghis
orhermedical,physical,emotional,andpsychosocialneeds,andhowyouplan
tomeetthoseneeds.
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Attheendofeachweek,youwillreflectonyourexperienceintheclinicalarea
andthenwriteaselfevaluationdocumentingyourthoughtsandfeelingsabout
yourperformance.Asatutor,Iunderstandthatmanystudentsareintimidated
by,orsimplyuneasyabout,theprospectofwriting.Worse,Ivemetquiteafew
whoclaimtohateit!Ifyoubelieveyourselftobeinoneofthesecategories,then
thismanualisforyou.Ithasbeendesignedtoeliminateanyreservationsyou
mayhaveaboutyourabilitytowritesuccessfully,andwithconfidence,by
showingyouexactlywhatyoucanexpectregardingcareplansandself
evaluations.Ihopeyouwillfindthisapracticalandvaluablelearningtoolas
youstriveforexcellenceintheclinicalarea.

Asyoumakeyourwaythroughnursingschool,strugglingandsacrificing,
pleasetakethetimetoremindyourself,often,thatyouhavebeenselectedfor
oneofthefinestnursingeducationprogramsinthisregionandthatyoucan,and
will,meeteachchallengesuccessfully,andberewardedbeyondmeasurefor
yourefforts.

LuanneBegin
StudentNurse,Classof2007
BristolCommunityCollege

ii


ACKNOWLEDGMENTS

Iwouldliketothankthefollowingpeople:

Dr.CynthiaHahn,formakingmelovechemistryandrecommendingmetothe
TutoringandAcademicSupportCentertherebyintroducingmetothe
wonderfulworldofbeingatutor.

Dr.RonaldWeisberger,whoseinfectiouspassionforpeertutoringinspiredmeto
helpothers,bothinsideandoutsidetheTASC.

ProfessorDianaDonnieMcGee,forencouragingmetobegintutoringinthe
WritingLabandinsistingthatIentertheCommonwealthHonorsProgramI
neverwouldhaveconsideredsuchathingwithoutherinfluence.

NicoleDeLano,forgenerouslysharingherFundamentalscareplans,beinga
friend,alwayshavingasmile,andfindingthetimetoinspireothers.

LynneCaron,forthewritingsamplessheprovidedtotheWritingLab;forthe
friendship,support,andencouragementthroughoutthese2years;foralways
pickingupthephonewhenIspeeddialedhernumber;and,ofcourse,forallthe
pancakesandcrazypneumonics.InotonlyearnedaNursingdegree,Igaineda
lifelongfriend.

Dr.HowardTinberg,forhistime,patience,anddedicationtothisstudent,and
towriterseverywhere;forhisspecialwayofhelpingawriterseethevalueof
theirwork;forhispraise,whichisalwaysgenerous,andhiscorrections,which
arealwaysgentle.Thisprojectwouldnothavebeenpossiblewithouthis
wisdom,insight,andguidance.

Finally,Ineedtothankmyfamily,forlivinginamessyhouseandeatingalotof
takeoutwhileIspenthourswiththecomputer.

TABLEOFCONTENTS

SectionOne:TheNursingProcess.................................1
Assessment....................................................1
Diagnosis......................................................1
Planning.......................................................2
Implementation.................................................3
Evaluation.....................................................3
SectionTwo:WritingaCarePlan..................................5
GettingStarted..................................................5
DataCollectionandOrganization.................................5
ConductingResearch............................................7
EvaluatingYourPriorities.......................................10
Revisions......................................................10
SectionThree:SampleCarePlans.................................12
Fundamentals:NUR11..........................................12
MedSurg:NUR51&52.........................................19
WhySuchLongCarePlans?.....................................39
SectionFour:SelfEvaluations....................................41
NUR11&12...................................................43
NUR51&52...................................................48
Afterword......................................................51
References......................................................52

*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~
Section One: The Nursing Process
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~

Potter&Perry(2005)describesthenursingprocessasasystemtoorganizeand
delivernursingcare(p.279).Asyoumayalreadyknow,thenursingprocess
consistsoffivesteps:assessment,diagnosis,planning,implementation,and
evaluation.Whileyouhavestudiedeachoftheseaspectsofthenursingprocess
indepthduringyourcorecurriculum,Ithoughtitmightbehelpfultoprovidea
briefoverviewofhoweachofthesestepsappliestocareplanning.

Assessment
Assessmentisthedeliberateandsystematiccollectionofdata(Potter&Perry,
2005).Thisistheveryfirststepinwritingacareplan.Indeed,itwouldbe
almostimpossibletocreateamapofcareforapatientaboutwhomyouhaveno
information.Ontheeveningbeforeclinical,youwillwriteyourcareplanbased
entirelyoninformationyouhavegatheredfromthepatientswrittenrecords.
Althoughyouhavenotyetseen,touched,smelled,orlistenedtoyourpatient,
thisresearchofthepatientschartisassessment.Itallowsyoutounderstandthe
patientshistory,reasonforadmissiontothehospital,currentmedications,
laboratoryvalues,andcurrenthealthstatus.Youcannotproceedtothenextstep
incareplanningwithoutit.Pleasetakemyadviceandconductathorough
examinationofyourpatientsmedicalrecord;youdonotwanttobeathome
writingacareplanonlytorealizethatyouaremissingacriticalpieceof
information.

Diagnosis
Nursingdiagnosesareclinicaljudgmentsaboutactualorpotentialproblemsa
patientmaybefacing.Basedonyourassessment,youwillidentifythenursing
diagnosesmostappropriateforyourpatient.TheNorthAmericanNursing
DiagnosesAssociation(NANDA)istheorganizationthatdefinesandclassifies
nursingdiagnoses.Itisrequiredthatalldiagnosesincludedinyourcareplanbe
NANDAapproved.ThisisimportantbecauseNANDAprovidesacommon
languagethatallnursesuseandunderstand.Youhavepurchasedarequired
textthatprovidesyouwithacomprehensivelistofNANDAapproved

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diagnoses.Earlyoninyourcareerasanursingstudent,youareexpectedtouse
onlythattextasaresource.Later,youmaybeallowedtouseseveraldifferent
textsonnursingdiagnosesand/orcareplanning,dependingonyourinstructors
preferences,aslongasallyourdiagnosesremainNANDAapproved.Ifyour
instructordoesnotobject,youwilldefinitelywanttoinvestintwoorthree
nursingdiagnoses/careplanningbooks.
Inyourfirstyearyouwillbeginbyidentifyingonediagnosis,thenprogressto
identifyingthree,andthenfive.Inyoursecondyearyouwillidentifyfifteen.
Youwillalwaysbeginwiththenursingdiagnosiswiththehighestpriorityfor
thepatient,andproceedtolisttherestinorderofdecreasingpriority.Todothis,
usetheBasicHumanNeedslist(appendixA).Generally,anactualdiagnosis
takespriorityoverariskfordiagnosis.Forexample,ImpairedSkinIntegrity(an
actualproblem)wouldbeahigherprioritythanRiskforInfection(apotential
problem).However,therecanbeexceptions,andmostofthese,thankfully,can
bediscernedwithcommonsense.RiskforInjurywouldnaturallytake
precedenceoverActivityIntolerance.
Thewritingprocessisimportantwhenitcomestodiagnosis.Youmayfindit
helpfultofirstthinkaboutandthenwritedownonapieceofscrappaper,
withoutregardtowhatismostimportant,anyandallproblemsyoubelievethe
patientmayhavebasedonyourassessment.Fromthere,youcancriticallythink
aboutandbegintorankyourdiagnosesaccordingtopriority,beforecommitting
toactuallywritingtheminyourcareplan.

Planning
Theplanningphaseofthenursingprocessiswhenyouwilldecidewhichcare
measuresareappropriateforyourpatient.Eachnursingdiagnosislistedinyour
textwillhaveacorrespondinglistofinterventionsandrationales.Planningcare
involvescarefullyreadingthougheachlistedinterventionandaskingyourselfif
thatinterventioncanorshouldbecarriedoutwithyourpatient.Forexample,an
interventionlistedunderImpairedGasExchangereadsasfollows:Ifthepatient
isobeseorhasascites,considerpositioninginreverseTrendelenbergsposition
at45degreesforshortperiodsastolerated(Ackley&Ladwig,2006,p.439).
Now,ifyourpatientisnotobeseanddoesnothaveascites,thisinterventionis
notindicatedandshouldnotbeincludedinyourplanofcare.Toreiterate,
includeonlythosecaremeasureswhicharerelevanttoyourpatient.
Itisveryimportantthatyoulearn,earlyon,howtomakeyourinterventions
specifictoyourpatient.TrustmewhenItellyouthatyouwilllikelysave

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yourselfalotoftime,andpossiblyavoidhavingyourcareplanreturnedtoyou
forrevisions,ifyouareconscientiousaboutdoingthis.Asanillustration,
supposeyouhaveadiagnosisofAcutePainandoneofthelistedinterventionsis
administeranalgesics,asneeded.Whatyouwillneedtodoislookatyour
patientsavailablemedicationsforpainreliefandwritetheinterventionas
follows:administerDilaudid,2mg,IVq4hours@0800and1200.Noticethat
themedication,dose,route,andscheduleislistedandthatthetimesarespecific
totheshiftwhenyouwillbecaringforthepatient.Also,becognizantoftheuse
ofpronounsinyourinterventions.Useheorshewhereappropriate.Thislets
yourinstructorknowthatyouaretailoringyourcaretoyourpatient.Youwill
seemoreexamplesofspecificityasyoulookatthesamplecareplansinthis
manual.
Eachoftheinterventionsyouplanhasacorrespondingrationale;ascientific
explanationforwhythatnursingcaremeasureisappropriate.Beginninginyour
secondsemesteryouwillberequiredtolistarationaleforeachofyour
interventions.Manystudentsfindthistobeatediousandsomewhat
superfluousstep.Iurgeyoutoexamineeachrationalecarefully,asitisan
importantcomponentofyourlearning.Asnurses,itisessentialthatwe
understandnotonlyhowwedothings,butwhywedothings.Rationalesreflect
whatresearchhasproventobebestpractice.

Implementation
Implementationissimplycarryingouttheinterventionsyouhaveidentified
asbeingnecessaryforyourpatientscare.PotterandPerry(2005)teachesthat
preparationforimplementationensuresefficient,safe,andeffectivenursing
care(p.344).Partofyourpreparationinvolveshavingathoroughcareplan
completedbeforeyouarriveforclinical.Thisismandatory,andforgoodreason.
Howelsewouldyouknowwhattodowith,andfor,yourpatient?Whenyou
reportforclinical,youmustassess/reassessyourpatientinordertodetermine
whetheryourplannednursinginterventionsarestillappropriateornecessaryfor
thepatient.Implementationinvolvesmanystepsincluding,butnotlimitedto,
directcare,counseling,teaching,andpreventionofcomplications.Awell
thoughtoutandcomprehensivecareplanguidesyouthroughthesestepsand
helpsyoupracticeefficiently,safely,andeffectively.

Evaluation
Thefinalstepinthenursingprocess,evaluation,allowsustodetermine
whetherouruseofthenursingprocesswaseffective.Itasksthequestion,Did
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thepatient(orthepatientscondition/wellbeing)improve?Eachnursing
diagnosisyouidentifyhasspecificandmeasurabledesiredoutcomes.
Evaluationisbasedonwhethertheexpectedoutcomeswereachieved,andnot
onwhetherspecificinterventionswerecarriedoutorhelpful.Thisisan
importantdistinctionandoneyouneedtounderstand.Forexample,adiagnosis
ofImpairedPhysicalMobilitysuggeststhefollowingoutcomes:

Patientwill(givespecifictimeframe):
Increasephysicalactivity
Verbalizefeelingsofincreasedstrengthandabilitytomove
Demonstrateuseofadaptiveequipment(specifycrutches,walker,
etc.)toincreasemobility

Now,whilesomeofyourinterventionsforthisdiagnosiswillincludetreating
thepatientspainbeforeactivity,usingagaitbeltwhileambulatingthepatient,
andincreasingindependenceofADLs,evaluationisnotbasedonwhetherthese
caremeasureswerecarriedoutsuccessfully.Rather,youwillbeevaluating
whetherthenursingprocesswaseffectiveasawhole.Youwilldocument,on
yourcareplan,whetheryoubelieveyourassessments,diagnoses,planning,and
implementationmeasureswerecorrectandaccurate,andyouwillneedto
providerationalestosupportyourposition.Rememberthatyourjudgments
mustbebasedonwhetheryourpatientmet,orisprogressingtowards,the
expectedoutcomes.
Yourwrittenevaluationisaddedtoyourcareplanafteryouhavecompleted
yourfirstdayofclinical.Basedonyourassessmentsandevaluations,youmay
needtochangeyourprioritiesfordaytwo;someofyourdiagnosesmaystillbe
pertinentwhileothersmayneedtobechanged.Payattentiontothispart:please
resistthetemptationtoleaveyourtopfiveprioritiesunchangedsimplybecause
youcangetawaywithit!Ihaveknownsomestudentswho,becausetheydid
notwanttohavetoworkupanothernursingdiagnosis,wouldkeeptheirtop
fiveinspiteofthefactthatchangingsomeofthemwouldhavebeenmore
appropriate.Iunderstandthataddingmoreworktoyourcareplanafterhaving
littlesleepandalongdayatclinicalisthelastthingyouwanttodo.However,
trustmewhenIsaythatdoingjustthatcontributestoyourclinicaleducation
andmasteryofthenursingprocess.Ifyoufailtobeconscientiousinthisarea
youarecheatingyourselfandyourpatients.

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*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~
Section Two: Writing a Care Plan
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~

Hopefully,younowhaveabasicunderstandingofhowandwhyweusethe
nursingprocessinordertoplancareforourpatients.NowIdliketoturnyour
attentiontothemethodicalstepswetakeintheactualwritingofacareplan.
Everyonehasauniquewritingprocess;fromgeneratingideas,organizingyour
information,andwritingthebodyofyourworktorevisingandediting,the
writingprocesscanvarybetweenindividuals.Iencourageyoutousethe
processthatworksbestforyou.However,forthepurposesofthismanual,Iwill
outlinetheprocessthatIfound,throughtrialanderror,tobethemostthorough
andefficientforme.Bearinmindthatthisisonlyamodel,andnotaconcreteor
mandatorywaytoaccomplishyourgoal.

GettingStarted
Youhavearrivedatyourclinicalsitetopickupyourassignment,dressed
professionallyandwearingyourcrisp,whitelabcoat,lookingverymuchlikethe
healthcareprovideryouaredestinedtobecome.Ifyouareafirstyearstudent,
youareprobablyfeelingabitapprehensive,becauseyouareunfamiliarwiththe
unittowhichyouhavebeenassigned,andyouarehesitantaboutenteringthe
strangeandforbiddenoasisknownasthenursesstationandsimplyplucking
yourpatientschartfromitsdesignatedspotor,worse,rightfromunderthenose
ofthesecretary.(Donteverdothat,bytheway.Thesecretaryisakeeperof
importantinformationandcanbeyourbestfriendorworstenemy.Alwaysask
herpermissionbeforeremovingachartfromherdomain.)Takeadeepbreath
andrelax.Goaheadandremovethechartyouneed,justbesuretoleaveanote
initsspaceindicatingthatastudenthasthechartandwhereyouwillbeonthe
unit.Thisisextremelyimportant,incasesomeonefromthemedicalteamshould
needitforanyreason.
Youarenowreadytofindaquietspotandbeginresearchingyourpatients
medicalrecordinordertoobtaintheinformationyouneedtowriteyourcare
plan.Haveanotebookready,andstartwriting.

DataCollectionandOrganization
First,letmewarnyouthatwritingyourcareplanmaytakeyoueight,ten,or
eventwelvehours.Pleasedontbealarmed,asthisiscompletelynormal.
Becausewritingyourcareplancanbesotimeconsuming,ithelpstoorganize
yourdatainsuchawaythatmakesiteasytofindandrefertoonceyougethome
andbegin.IfoundthatIsavedmyselfalotoftimebyorganizinginformationin
alinearfashionthatparalleledtheformatofthecareplan.Here,Illsharewith
youmymethod,thoughagain,bearinmindthatyouarenotobligatedtofollow
myexample.

BasicInformation
Beginbywritingdownthefollowing:yourpatientsinitials,age,dateof
admission,dateofsurgery(ifapplicable),admittingdiagnosis,codestatus,and
anyallergies.Thisinformationwillbeincludedonthefirstpageofyourcare
plan.

Knowyourpatientsfullname,butdonoteverwriteitinyournotesoronyour
careplan.Rememberthatallinformationisconfidentialandthatyouaretaking
quiteabitofitoutofthehospitalandintoyourhome.Ifyournotesshould
somehowbemisplaced,lost,stolen,orleftlyingsomeplacewhereothersmight
readthemandthepatientsnameisonanypage,theirprivate,privileged
informationwouldbecompromisedandyouwouldbeinviolationoftheHealth
InformationPortabilityandAccountabilityAct(HIPAA).Pleasetakeevery
conceivablemeasuretoprotectyourpatientsidentity.

SignificantPastHistory(includingsocialhistory)
Noteanyhealthissuesormedicaldiagnosesthatyourpatienthas(suchas
diabetes,hypertension,coronaryarterydisease,emphysema,etc.)otherthanthat
whichbroughtthemtothehospital.Listanyprevioussurgeries.Takedown
theirsocialhistorysuchaswhotheylivewith,inwhattypeofhome,whether
theyhavefamilyorothersourcesofsupportandcare,ifthereisanadvanced
directiveinplaceand,ifso,whattype,anyculturalorreligiousconsiderations,
andwhethertheysmokeorusealcoholorillegaldrugs.

ReasonforPresentAdmission
Whyisthepatientinthehospital,howdidshecometobethere,andwhat
washerconditionuponarrival?Yournoteshereshouldfocusonthedetails
surroundingtheircurrenthospitalstay.

SignificantEventsSinceAdmission
Hereiswhereyouwillmakenoteofanysignificantornewfindingssincethe
patientcametothehospital.Besuretolookupanydiagnosticssuchasxrays,
ultrasounds,CTscans,MRIs,orEKGsandincludetheirfindings.Any
complicationsthathavedeveloped,additionalsurgeries,ornewtreatments
shouldalsobenoted.

LaboratoryValues
Makealistofallabnormallabvalues.Thosewithinnormalrangeshouldnot
beincluded.

Medications
Makealistofallthepatientsmedications.Althoughthereisusuallya
medicationlistinthechart,itisbettertoworkfromthepatientsmedication
administrationsheet.Itletsyouknowwhichmedshavebeendiscontinuedor
added,andismorecurrentthanthelistinthechart.Itmaybehelpfultomake
twomedicationlists:oneforscheduledmedsandanotherforPRNs.These
medsheetsarekeptindifferentlocationsatdifferentfacilities.Youwilllearn
theirlocationonyourfirstvisittoyourassignedunit.Aswiththechart,always
leaveanotethatyouhavethemedsheetsandwhereyouwillbeontheunit.

Kardex
TheKardexesarelocatedatthenursesstation,usuallynearthesecretary.
Thisiswhereyouwillfindinformationaboutthepatientsdiet,permitted
activity,IVfluids,whetherhehasacatheterinplace,ifheisonoxygen,typesof
dressingsandscheduledchanges,andanytestshemaybescheduledfor.

ConductingResearch
Onceyouhaveallthenecessaryinformation,itstimetogohomeandbegin
doingresearch.Again,yourpreferredwritingprocessshouldbeapplied.You

7
maychoosetodoallyourresearchbeforeyoubeginwriting,oryoumaydoitas
youwrite.Eitherway,clearsomespacearoundyouandpreparetohaveseveral
booksavailableatarmsreach.

ResearchingYourPatientsCondition
Youneedtohaveatleastabasicunderstandingofanymedicalconditionor
surgeryaffectingyourpatient.Inyourfirstsemesterofnursingyouarerequired
towriteout,verbatim,thedefinitionsofthesemedicalconditionsandsurgeries,
citingyoursources.Inlatersemesters,youwilllikelypossessaknowledgebase
aboutmostofthehealthcareissuesyouwillbedealingwithinclinical.
However,whenyoudontknow,besuretolooktheissueupandunderstandit
beforeyouwriteyourcareplanandreporttoclinical.Sourcesforthis
informationincludeyourFundamentalsandMedicalSurgicaltextbooks,and
MosbysMedicalDictionary.

ResearchingNursingDiagnoses
YourNursingDiagnosisHandbook,byBettyAckleyandGailLadwigisthe
primarysourcefornursingdiagnoses.First,criticallythinkandtrytoidentify
whatyourpatientsdiagnosesmightbe.Then,openupAckley,whereyouwill
findanalphabeticallistofmedicalconditionsandsurgeries,andcommon
nursingdiagnosesforeach.Asyouconsideradiagnosisforyourpatient,findit
inAckleyandreaditsdefiningcharacteristicsandrelatedfactors.Simplydoing
thatshouldletyouknowifthediagnosisisappropriateforyourpatient.
Onceyouhavecompletedyourlistyouwillworkupyourtopdiagnoses.
Thisincludeswritingoutallassessments,interventions,andrationales.Inyour
firstyear,youarerequiredtociteyoursourceforthediagnosisandallrationales.
Asmentionedpreviously,takethetimetoreadthrougheachintervention,
chooseonlythosethatareappropriatefor,andmakethemspecificto,your
patient.

ResearchingLabsandDiagnosticTests
Asofthiswriting,theresourceforthisinformationisAManualofLaboratory
andDiagnosticTestsbyFrancesFischbach.Youwillutilizethisbooktoevaluate
laboratoryvaluessuchasredbloodcellcount,hemoglobin,hematocrit,white
bloodcellcount,urinalysis,electrolytes,etc.Itprovidesindicationsastowhya
particularlabvaluemaybehighorlow.Inaddition,itoutlinesproceduresfor
collectingspecimens.Diagnostictestsarealsoexplained,withinstructionsfor
preparingthepatientfortestingandhowtocareforthemafterwards.Many

8
times,whenyoureadadiagnosticreportinthepatientschart,itwillprovidean
interpretationofthefindings.Ifbyrarechancethisisnotthecase,youmaybe
abletodiscernanexplanationinthetextbook.However,ifyouarenotsure
whatthefindingsofadiagnostictestmaymean,donttrytoguess.Bringyour
questiontoyourclinicalinstructor,whowillassistyouindeterminingthe
significanceofanyfindings.

ResearchingMedications
YouwillresearchmedicationsinSpringhousesNursesDrugGuide.Foreach
medicationonyourlistyouwillneedtoprovideitsgenericandtradename,
dose,route,schedule,timesdue,pharmacologicalclass,therapeuticclass,mode
ofaction(chemicaleffect),andsafedose.Inaddition,youmustprovidethe
reasonthepatientistakingthemedication,potentialsideeffectsandinteractions,
andallnursingresponsibilitiesrelatedtoadministeringthatmedication.
Ifyouprepareyourcareplansonthecomputer,Istronglyrecommendthat
youkeepadatabaseofeverymedicationthatyouresearchandwriteup.You
willlikelyadministerseveralmedicationsrepeatedlythroughoutyourtwoyears
innursingschool.Youwillsaveyourselfanincredibleamountoftimeifyou
copyandpastethesemeds;youwillthenonlyneedtochangethedose,route,
schedule,timesdueandreasonthepatientistakingthemed,asnecessary.Be
advised,though,thatclinicalinstructorsfrownonthispractice.Theirconcernis
thatyouarenotthoroughlypreparedtogivethemedicationandmaybe
cheatingyourselfoutofvaluablelearningbyskippingtherepetitionoflooking
upandwritingoutthemedeachtimeyouhavetogiveit.This,ofcourse,isa
completelyvalidargument.However,asbusynursingstudentsyourtimeis
valuableandyouneedtouseitaseffectivelyaspossible.Keepingadatabaseof
medsisonewaytoaccomplishthat.Justdontdoitattheexpenseofyour
patients.Bediligentandconscientiousandknoweverythingyouneedtoknow
tosafelyadministerthatmedication.Yourpatientswellbeing,indeedtheir
lives,dependsonyourdoingthat.Also,whencopyingandpasting,bearin
mindthatyourinstructormayquizyouaboutthatdrug,andifshedoes,youd
betterhavetheanswerstoherquestions.Ifyoudont,youmayearnyourselfa
clinicalwarning.

WritingUpDiagnoses,Interventions,andRationales
Beginninginyoursecondsemesteryourcareplanwillhavethreecolumnsfor
this.Inthefirstcolumnyouwillwriteyourdiagnosisintwoorthreeparts,
dependingonyourinstructorspreference.Forexample,atwopartdiagnosis

9
wouldreadasfollows:ImbalancedNutrition,lessthanbodyrequirementsr/t
lossofappetite.Thisstatesthediagnosisandthefactoritisrelatedto.Athree
partdiagnosisdoesthesame,withtheadditionofstatingthedefining
characteristics.Athreepartdiagnosis,then,wouldreadlikethis:Imbalanced
Nutrition,lessthanbodyrequirementsr/tlossofappetitem/brecent30pound
weightloss.Yournursingdiagnosisbookprovidesalistofrelatedfactorsand
definingcharacteristicsforeachdiagnosis.Underyourdiagnosisyouwill
providealistofsubjectiveandobjectivedatatosupportit.
Themiddlecolumnisforlistingyourinterventions.Youwillberequiredto
breakthemdownintothreesections,whichwilldifferinyourfirstandsecond
year.Thismayseemabitconfusing,butwillbeexplainedandbecomeclear
whenyoulookatthesamplecareplansprovidedinthismanual.
Thethirdcolumnisforlistingtherationaleforeachintervention.Each
interventionandcorrespondingrationaleshouldbenumberedandlineupnext
tooneanotherineachcolumn.Thisorganizesyourcareplan,makesitneatand
presentable,andsavesyourinstructorfromeyestrain.

EvaluatingYourPriorities(NUR51&52)
Afterthefirstdayofcaringforyourpatientyouwillberequiredtowritean
evaluationoftheachievementofyourpriorities.Yourprioritiesfordayoneare
yourtopnursingdiagnoses(threeinyourfirstyear,fiveinyoursecond).
Evaluatingyourachievementrequiresyouthinkaboutwhetherthatdiagnosis
wasaccurate,whyyoubelieveitwasorwasnot,andwhatyourplansare
regardingthatdiagnosisfordaytwo.Shouldyoucometorealizethatoneof
yourtopdiagnosesisnolongerappropriate,youwillneedtomoveothersupthe
listorreplaceitwithanewdiagnosis.Youwill,ofcourse,havetowriteupthe
interventionsandrationalesforanyadditionsorchangestothetoppriorities.

Revisions
Youmaymakerevisionstoyourcareplanatanytimebeforegivingittoyour
instructor.Beprepared,though,tohanditoverattheendofyoursecond
clinicalday.Hopefully,itisorganized,thorough,detailed,andaccurateand
comesbacktoyouwiththewordSatisfactorywrittenacrossthetop.Ifit
doesnt,dontbediscouraged.Mostinstructorswillallowyoutomakerevisions
wheretheyhaveindicated,andifyoudothatandturnitbackintheywillaccept
itandchangeittosatisfactory.Sometimes,evenafterrevisions,acareplanjust
cantbesalvagedandyourinstructorwillnotacceptanymorechanges.Atthat
point,youwillsimplyhavetoputthatcareplanbehindyouandputyourbest
effortsintothenextone.

Aswithanynewchallenge,whenyoufirstbeginwritingcareplansitmay
takesometimetogetthingsexactlyright.However,witheachpassingweek
therewillbeimprovementuntilyouarewritingcareplanswithconfidenceand
ease.Asyouadvancethroughnursingschooltheacademiccurriculumand
clinicalrequirementsbecomemorechallenging.However,althoughthepatients
youcareforbecomemorecomplexand,therefore,thecareplansmore
complicated,theyactuallybecomeeasiertowrite.Learningisbasedonprevious
knowledgeandexperience,andasyouprogressthroughnursingschoolyouwill
findyourselfassimilatingdatamorequicklyandefficiently,andcompletingyour
careplansinamoretimelymanner.Everyonestartsoutslowly,buttime,
practice,andexperiencewillhaveyouwritingcareplansthatnotonlyprovidea
mapofcareforyourpatients,buthelpyougrowasaproviderofthatcareinthe
professionofnursing.

11
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
Section Three: Sample Care Plans
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*

InthissectionyouwillfindsamplesofcareplansforNursing11
(FundamentalsofNursing)andNursing51and52(NursingCareoftheAdult).
IregretthatIcouldnotincludesamplecareplansforNursing12(ParentChild
Nursing).Asyouwillsoonlearn,ifyouhaventalready,obstetricsand
pediatricsarespecializedareasandtheprocessofwritingcareplansand
obtaininginformationforthemisvastlydifferentfromthatwhichIhave
outlinedhere.However,therearecopiesofobstetric(laboranddelivery,
postpartum,andnewborn)andpediatriccareplansavailableforreviewinthe
writinglab.

Fundamentals:Nursing11CarePlans
WhatfollowsisasampleofaNursing11careplan,whichconsistsofthree
phases.Asyousuccessfullycompleteonephase,youwillmoveontothenext,
untilyouarewritingacompletecareplan.Inthesample,Ihaveindicatedon
eachpagewhichphaseitispartof.
Asyouwillsee,pageoneconsistsofblockswhichareselfexplanatory.You
willsimplyneedtofilltheminwiththeappropriateinformation.
Pagetwolistsallyourpatientsdiagnosesandsurgeriesanddefinesthem
Themedicationpagelistsallmedicationsthepatientistaking.Ihave
workeduponlytwo,foryoutouseasamodel.
Next,thereisapagerequiringyoutolistyourtopthreenursingdiagnosesfor
eachdaythatyouwillbeprovidingcare,andasectionforprovidingsocio
culturalinformation.
Finally,thereisasampleofanursingdiagnosisanditsinterventions.Asyou
willsee,yourinterventionsmustbebrokendownintothreesections:
Assessments,Interventions,andTeaching.Someinformationmayberepeatedin
morethanonesection,whichisacceptable.Again,Ihaveworkeduponlyone
diagnosis.Followingthemodelprovided,youshouldhavenodifficulty
completingallthreeofyourrequireddiagnoses.

12
 BristolCommunityCollege
NUR11:NURSINGCAREPLANPHASEI

Student name: Patient initials: Clinical Date

Rm. # Admitting Diagnosis I&O Diet Assessments Tuesday/ Findings Wednesday/ Findings
Tuesday LOC,
Physician Mental Status,
I: Orientation
Nurse Hygiene Pain Assessment

Code status O: Lung Sounds O2 Saturation

Precautions Secondary Diagnoses Wednesday Activity Bowel Sounds (Assess all 4

quadrants)
Allergies I: Last BM
Extremities (Pulses, CMS,
Homan's)
O:

Treatments/ Procedures Specimens to obtain & Diagnostic Vital Signs Neurological Checks (PERRLA)
List the materials needed and any procedures to be done on your time IV Therapy Assessments Site
procedure steps Flow
Tuesday Complications
T Other
P Medications
R List all medications that you will administer & times due

B/ P IV Therapy (Solution and Rate)

Wednesday
T Scheduled Medications PRN Medications
P
R STAT or One Time

B/ P
DefinitionofMedicalDiagnosesandSurgery
AdmittingDiagnosis
RenalFailure:theinabilityofthekidneytoexcretewastes,concentrateurine,andconserveelectrolytes.Thecondition
maybeacuteorchronic(MosbysMedicalDictionary,p.1485).
Citeyoursource!

SecondaryDiagnoses
Angina:aparoxysmalthoracicpaincausedmostoftenbymyocardialanoxiaasaresultofatherosclerosisorspasmofthe
coronaryarteries.Thepainusuallyradiatesalongtheneck,jaw,andshoulderanddowntheinneraspectoftheleftarm.
Attacksofanginapectorisareoftenrelatedtoexertion,emotionalstress,eating,andexposuretointensecold.Thepain
mayberelievedbyrestandvasodilationofthecoronaryarteriesbymedication(Mosby,p.96)
Arthritis:aninflammatoryconditionofthejoints,characterizedbypain,swelling,heat,redness,andlimitationof
movement(Mosby,p.136)
AtrialFibrillation:acardiacarrhythmiacharacterizedbydisorganizedelectricalactivityintheatriaaccompaniedbyan
irregularventricularresponsethatisusuallyrapid(Mosby,p.154)
CongestiveHeartFailure:anabnormalconditionthatreflectsimpairedcardiacpumping.Itscausesincludemyocardial
infarction,ischemicheartdisease,andcardiomyopathy(Mosby,p.416).
SickSinusSyndrome(SSS):acomplexofarrhythmiasassociatedwithsinusnodedysfunction.Theconditionmay
resultfromavarietyofcardiacdiseases,rangingfromcardiomyopathiestoinflammatorymyocardialdisease.Itismost
commonlyrelatedtoeitherintermittentSAblockorinadequateSAconduction.SickSinusSyndromeischaracterizedby
severesinusbradycardia,eitheraloneoralternatingwithtachycardia,oraccompaniedbyatrioventricularblock.The
mostcommonsymptomsarelethargy,weakness,lightheadedness,dizziness,andsyncope(Mosby,p.1580).

Surgeries
Pacemaker:electricalapparatususedtoincreasetheheartrateinseverebradycardiabyelectricallystimulatingtheheart
muscle(Mosby,p.1259).
THISPAGEISINCLUDEDINPHASEONE14



NURSING11CAREPLANPHASETWO
Nameofdrug
Dose
Route
Timesdue
Classifications
SafeDose
spironalactoneAldactone Drugaction:antagonizes
25mg
PO2xdaily Generic and
trade names
0800/2000
Pharmacologicalclass:
potassiumsparingdiuretic
Therapeuticclass:
managementofedema,
antihypertensive,diagnosisof
primaryhyperaldosteronism,
treatmentofdiureticinduced
hypokalemia
Safedose:upto100mgdaily
potassiumchlorideKTab Drugaction:aidsin
20mEq
POdaily
0800
Pharmacologicalclass:
potassiumsupplement
Therapeuticclass:mineral
Safedose:upto50mEqtwice Reasonptisonmed:CHF
daily
Meds are part
of phase 2
Medications
DrugAction List3sideeffects
Reasonpatientison Listallsignificantnursing
medication(bespecific) actionsrelatedtothe
administrationofthismed
Observeforheadache,
aldosteroneindistaltubule; diarrhea,dehydration
promoteswaterandsodium
excretionandhinders Always preface side
potassiumexcretion,lowers effects with observe for
bloodpressure,andhelpsto
diagnoseprimary 1.Givedrugwithmealsto
hyperaldosteronism enhanceabsorption
2.Protectdrugfromlight
Reasonptisonmed:totreat 3.Monitorelectrolytelevels,
hypertension fluidintakeandoutput,and
BPqshift(0800/1600/2400)
Number all nursing actions. 4.Bealertforadverse
You will find these listed with reactionssuchas
each med under nursing
hyperkalemia,angioedema,
process
confusion,anddrowsiness
5.Bealertfordrug
interactionssuchaspotassium
chloride
ObserveforEKGchanges,
transmittingnerveimpulses, abdominalpain,weaknessof
contractingcardiacand limbs
skeletalmuscles,and
maintainingintracellular 1.Givecautiously;differentK
tonicity,cellularmetabolism, supplementsdelivervarying
acidbasebalance,andnormal amountsofK.Neverswitch
renalfunction.Replacesand productswithouta
maintainspotassiumlevels. prescribersorder
2.Givewithoraftermeals
withafullglassofwater
3.Makesurepowdersare
Note that there may be an
interaction between these completelydissolved
meds. You may want to 4.Monitorrenalfunction,fluid
emphasize this in red, or intakeandoutput
by marking it with a 5.MayinteractwithKsparing
highlighter diuretics


 NUR11NURSINGCAREPLAN
THREEMOSTIMPORTANTNURSINGDIAGNOSES

IncludepagenumberfromNUR11requirednursingdiagnosisbook

Tuesday
1. Oxygenation:DecreasedCardiacOutputr/tdysrhythmia(p.136)
2. Elimination:ImpairedUrinaryEliminationr/tdiuretictherapy(p.787)
3. Safety:ImpairedSkinIntegrityr/tprolongedimmobility(p.584)

Category of Diagnosis Related to (what is causing

Cite page
basic human this problem)
number
needs


Wednesday
1.
2. Your diagnoses may remain the same or, after you have
reassessed the patient, change for day 2.
3.

ImplicationsforNursingCareRelatedtoCulturalBackground
(considerlanguage,religion,ethnicity,andsocialorganization)

PatientisEnglishspeakingandlivesaloneinasinglestoryhouseandreceives
mealsdailyfromMealsonWheels.Sheisaretirednurseandisactiveinher
community.SheisadevoutRomanCatholicandattendsMassregularly.

THISISPARTOFPHASETWO
16

 NursingDiagnosis NursingInterventions
DecreasedCardiac Assessments
Outputr/tdysrhythmia 1. Assessrateandqualityofapicalandperipheralpulsesqshift
(Carpenito,p.136) @0800,1600,2400
2. AssessBPandanyorthostaticchangesqshift@0800,1600,
2400,andbeforeambulatingpatient
List all 3. Assesslungsoundsqshift@0800,1600,2400.Noteany
assessments occurrenceoforthopnea
you will 4. Assessforcomplaintsoffatigueandreducedactivity
perform. Be tolerance.Determinewhatlevelofactivitycausesfatigueor
specific about exertionaldyspnea
times.
5. Assessurineoutputqshift@0800,1600,2400
6. Assessforanychangesinmentalstatuswhileperforming
neurochecksqshift@0800,1600,2400
7. Assessoxygensaturationwithpulseoximetryqshift@0800,
1600,2400andduringactivity
Interventions
1. Monitorandrecordintakeandoutputqshift@0800,1600,
2400
2. Monitorforsymptomsofheartfailureanddecreasedcardiac
output;listentoheartandlungsounds;noteanyorthopnea,
dyspnea,fatigue,weakness,adventitiouslungsoundssuch
ascracklesorrales
3. Observeforchestpainordiscomfort;notelocation,radiation,
severity,quality,duration,andassociatedmanifestations
suchasnausea,indigestion,anddiaphoresis;alsonote
List the specific precipitatingandrelievingfactors.
labs you will 4. MonitorlabworksuchasCBC,sodium,potassium,and
monitor creatininelevel
5. Graduallyincreaseactivitywhenthepatientsconditionis
stabilizedbyencouragingslowpacedorshortperiodsof
activitywithfrequentrest:observeforsymptomsof
intolerance
a) TakeBPandpulsebeforeandafteractivityandnote
changes
6. Monitorbowelfunction.Administercolace100mgPOdaily
@0800,asprescribed
a) Cautionpatientnottostrainwhendefecating
b) Haveherusethecommodefortoiletingandavoiduseof
bedpan
7. Observeforsyncope,dizziness,palpitations,orfeelingsof
List specific meds weaknessassociatedwithanirregularheartrhythm
related to this 8. Administerspironolactone25mgPO@0800;potassium
diagnosis chloride20mEqPO@0800asprescribed
9. Observeforsideeffectsfromcardiacmedications
Teaching
1. Teachstressreductiontechniquessuchasguidedimagery,
 controlledbreathing,musclerelaxation
2. Explainnecessaryrestrictions,includingtheneedfora
sodiumrestricteddiet,guidelinesonfluidintake,andthe
Reference to avoidanceoftheValsalvamaneuver
volunteer work is 3. Teachtheimportanceofpacingactivities,includingvolunteer
specific to this work,andtheneedtorestbetweenactivitiestoprevent
patient. becomingoverfatigued
4. Teachherabouttheactions,sideeffects,andimportanceof
takingcardiovascularmedications
5. Providespecificwrittenmaterialsandselfcareplanforher,
orhercaregivers,touseasareference
6. Instructherontheimportanceofgettingapneumonia
vaccine(usuallyonceperlifetime)andfluvaccines(yearly)
asprescribedbyherphysician

THISISINCLUDEDINPHASETHREE

18
MedSurg:Nursing51&52CarePlans
Followingisasampleofanursing51medicalsurgicalcareplan.Youwill
noticethatitcontainsmoreextensiveinformationthantheNUR11careplanand
isquitedifferentinformatfromtheOBandpediatriccareplans.
AswithNUR11,yourinterventionsmustbebrokendownintosections.
However,formedsurgtheyshouldappearasfollows:Assess,Prevent,and
Evaluate.UnderAssessyouwilllist,ofcourse,allnecessaryassessmentsforthat
diagnosis.UnderPrevent,listallinterventionsyouplantoperforminorderto
preventfurtherdeteriorationof,andhopefullyimprove,yourpatientscondition
andwellbeing.UnderEvaluateyouwilllisttheexpectedoutcomesforyour
diagnosis.
Inordertogiveyouacomprehensivepictureofwhatyourcareplanshould
looklike,thesampleIhaveprovidedispresentedinitsentirety.

19

BRISTOLCOMMUNITYCOLLEGE
FallRiver,MA
CAREPLAN
NUR51&52
Name: Patientsinitials: Diagnosis:cellulitis,Lupperthigh
Date: Age:44 Surgery:N/A
AdmissionDate: Allergies:morphine, Dateofsurgery:N/A
cephalosporins

SignificantPastHistory(includingsocialhistory)
Patientisamarried44y/ofemale.Historyrevealsarecentcervicalspineinfection
resultinginafractureandsubsequentquadriplegia.Thecspineinfectionisspeculated
tohavearisenfromanundiagnosedcystwhichburst.Patienthadalonghospitalization
followedbyrecuperationat______________NursingHome,whereshehasbeen
residingforthelast2months.Herhusbandisdisabledandtheyrecentlylosttheir
home,duetotheirrespectivemedicalconditionsandfinancialhardship.Their2
adolescentchildrenarestayingwithrelatives.Thereisadistanthxofdrugabusewhich
predatesthecspineinfectionbyseveralyears.Patientidentifiesherreligionas
Catholic.Sheisafullcode,astherearenoadvancedirectivesinplaceatthistime.

ReasonforPresentAdmission
Patienthaspressureulcersonbothshoulderblades,coccyx,andRhip.Herlefthipand
theanteriorandlateralaspectsoftheLthigharered,edematous,andwarmtothe
touch.Shewascomplainingofneckspasms,morepronouncedontheleftthantheright.
Shedevelopedafever,hermentalstatusappearedtodeteriorateandshewasbroughtto
theERat__________Hospital.Hertemperaturewasrecordedat103.5.Alumbar
puncturewasperformed;theresultswerenegativeformeningitis.Shecomplainsofnot
feelingwell,andbeingachyalloverx34days.Thereissomedistensionofthe
abdomen,buttherehavebeennochangesinbowelhabits.Diagnosisiscellulitisofthe
Lupperthigh.

D5NS@100cc/hr This information will be found on the

Foleycatheter Kardex. There is not a specific place for
it on your care plan, so you may write it
Regulardiet in anywhere.
FlushGtubewith30ccH2Obeforeandaftermeds TIP: orders and treatments such as
Coccyx:aquagelwith1rollofgauze,coverwithDSD these can change at any time it is best
to re-check the Kardex on the morning
of clinical, and write these on your care
plan when you come in, rather than
typing them in the night before.

SignificantEventsSinceAdmission
Date:CXRrevealscephalizationwithinterstitialopacities.Mayreflectvolumeoverload
orunderlyinginterstitiallungdisease.Nopleuraleffusion,consolidationor
pneumothorax.
Date:AttempttoinsertPICClinetoleftantecubitalregionunsuccessfulafter3attempts.
NursetoconsultwithMDaboutalternativeoptions
Date:Patientcompletedassessmentformsforpainclinic.Awaitingassessmentby
woundclinicandPT/OT
Date:TriplelumencentrallineplacedRUC.PlacementcheckedbyportableCXR

This section consists of the

findings of your head-toe
SummaryofPatientStatusatEndofDay1 physical assessment.
Vitalsigns:0700101.3771694/5995%RA
1130101.1751789/5497%RA

Patientalert&orientedx3formostoftheday,withperiodicnaps.Lungsareclearbilaterally;
abdomensoftwithpositivebowelsoundsx4quadrants.Calvesappearnormalwithnoredness,
edema,orwarmth;positivebilateralpedalpulses.Thereisasmallareaofrednessonthetipof
theRgreattoe,whichIoutlinedwithmarker,nursemadeaware.Heelsintactwithnoredness.
Skinisdrywithsomeflaking.Lipsaredry,butinspectionoftheoralmucousmembranesshows
adequatemoistureandnolesions.ThereismarkedrednessandheatovertheLhipandthe
anteriolateralaspectoftheLupperthighrelatedtothecellulitis.Entireareacircledbynurse,in
ordertoevaluateanyrecessionorprogression.Woundtococcyxnotinspected,aspatientis
awaitingaconsultfromthewoundclinic.Dry,sterile4x4replacedover1cmcircularwoundon
Rshoulderblade;someserosanguinousdrainagepresent.Patientc/odiscomfortofherneckand
back;performedfrequentpositionchanges,takingcaretoensureproperbodyalignment.Area
aroundFoleycatheterinspectedandcleaned;noredness,edema,dischargeorodorpresent.IV
siteonRhandpatent.Patientc/oburninganditchingwhileUnasynbeinginfused.Site
inspectedbynurse;nochangeoftemperatureorcolorofskin,noedema.Infusionslowedand
warmpackappliedtosite.Patientate100%ofbreakfast,30%oflunch.POfluidintakewas
approximately860ccs.Urineoutputof450ccs(64cc/hr),appearanceyellowandconcentrated.
Patienthad1largebowelmovementmidmorning.Afternoonvitalsrevealedpatienttobe
febrile@101.1withaBPof89/54.NursemadeawareandinformedmethatBPconsistentlyruns
low.AnorderforTylenol1000mgPOq6hourswaswrittentoday.
Day2:
Vitals:070099.78020102/6996%RA Your day 2 vitals and any new
treatments will be written in by hand
110098.77418122/6996%RA
before you pass in your care plan
Vancomycin:peak32.6,trough8.0
Woundcareconsult:treatmentplanistochangedsgtococcyx2xday.IrrigatewithsterileH2O,
coatpackingwithtripleantibiotic,coverwithDSD.
Youshouldalsolistyourday2labs!

21
 In order of priority; may
change for day 2

PriorityNursingDiagnosisObjectiveTestData
W TH Test&Norms Results& Interpretation
Dates
1 1 ImpairedSkinIntegrityr/t Sodium 213:131 Slightlydecreaseddueto
immobility,pressure 135145 214:135 sweating(febrilex3
days),deficientdietary
intake
2 2 RiskforInfectionr/topen
Slightlydecreasedwith
wounds Chloride 213:96
sodiumloss
96107 214:102

3 3 RiskforIneffectiveTissue Slightlydecreasedto
Perfusion,peripheralr/t Potassium 214:3.2 sweating,draining
interruptedvenousflow 3.55 wounds,inadequate
secondarytoprolonged dietaryintake
immobility
Glucose 213:121 Slightlyelevated;maybe
4 4 Powerlessnessr/tlossoffunction 70110 r/tmeds


Decreased;maybedueto
5 5 ChronicSorrowr/tpermanent BUN 213:5
lowproteinintake,
disability 821 214:5
malnutrition
Decreasedduetolow
6 6 ChronicPainr/tdiseaseprocess Creatinine 213:0.4 protein,decreased
0.51.2 214:0.3 musclemass,
7 7 DisturbedBodyImager/ttrauma malnutrition
(quadriplegia)
Prealbumin 213:17.7 Decreasedduetolow
8 8 IneffectiveProtectionr/t 1836 protein,malnutrition

abnormalbloodprofile(seelabs)
Notsignificant.Level
Protein(CSF) 213:45.8
mustbemoderatelyto
9 9 ImpairedBedMobilityr/tneuro 1545
markedlyincreasedto
muscularimpairment suggestinfection
(classificationlevel4:doesnot
participateinactivity) WBC 213:15.4 Acuteinfection(cellulitis)
311 214:7.3
10 10 ImbalancedNutrition,lessthan
bodyrequirementsr/tlossof MCV 213:80.2 RBCsareslightly
appetite(wgt:125lbsBMI:20.2) 8296 214:81.7 microcytic


Acute,localizedinfection,
11 11 SelfcareDeficit, Include Neutrophils 213:88%
specifics inflammation
bathing/hygiene, 4283%

dressing/grooming,toiletingr/t Decreased;maybedueto
neuromuscularimpairment Lymphocytes 213:5% debilitatingillness
1347% 214:6.9%

12 12 SexualDysfunctionr/taltered UrinepH 213:>9 Mayber/tpotassiumloss
bodyfunction 56

Relatedtoirondeficiency
13 13 DeficientDiversionalActivityr/t RBC 214:3.78

disability,environment 3.965.27



14 14 RiskforAutonomicDysreflexia HGB 214:10.5 Duetoanemia
r/tspinalinjury 11.615.5
Indicatesanemia.Likely
15 15 RiskforDisuseSyndromer/t HCT 214:30.9 irondeficient(if
paralysis 3547 microcytic,RBCsand
HCTdonotparallel)





Although not required, you
may want to type lab values
in a different color, or mark
them with a highlighter to
help them stand out for easy
reference.



















23
NursingPrioritiesforDay1 EvaluationofPriorityAchievement
ImpairedSkinIntegrityr/t Thiswasanaccuratediagnosisand
immobility,pressureonbony importantpriority.Patienthasan
prominences openwoundonthecoccyx,and
woundsonbothshoulderblades.
Evaluate whether Herimmobilitypresentsachallenge
your diagnosis was, inthatitmaybedifficulttopromote
or was not,
healingandpreventnewwounds,
appropriate, and why
astheptisalmostconstantlyonher
back.
RiskforInfectionr/topen Patientatincreasedriskfor
wounds infectionofherwounds,particular
lytheoneonhercoccyxduetoits
depthandproximitytotheanus
(sheisoccasionallyincontinentof
stool)
RiskforIneffectiveTissue Iamnotentirelyconfidentthatthis
Perfusion,peripheralr/t diagnosisisatop5priority.There
interruptedvenousflow areotherswhichcouldeasilymove
secondarytoprolonged upthelist.Patientisbeingtreated
immobility withLovenox40mgSCdaily;
however,sheisunabletoperform
ROMexercises,andtheabsenceof
compressionstockingsconcernsme.
DevelopmentofaDVTand
progressiontoapulmonary
embolismisarealdanger...
symptomscoulddevelopsilently,as
theptisunabletoreportchangesin
sensation
Powerlessnessr/tlossof Powerlessnessisahugeissuewith
function thispt.Shedemonstratesbehaviors
atthelow,moderate,andsevere
level.Herlackoffunctionisonly
onecontributingfactor(sheis
completelydependentonothersfor
care).Anequalportionisdirectly
relatedtoherperceivedlackof
controloverdecisionsandwhat
happenstoher.Shehasbeen
NursingPrioritiesforDay2
Thisremainsapriorityat#1.
Iwouldliketoviewand
measureherexisting
wounds,ifthewound
consultanthasnotdoneso
(ptdueforconsultonday
one,afterIleft)
Thisdiagnosisremainsat#2,
forthereasonsstated.Iwill
checkherfrequentlyfor
incontinenceandcleanher
promptlytoavoid
contaminationofherwound
Iwillkeepthisdiagnosisat
#3,abovepowerlessnessand
chronicsorrow,onlybecause
itispotentiallylife
threatening.Iwillspeakto
herprimarynurseabout
obtaininganorderforTEDS
orpneumaticstockings
If your diagnosis remains
the same, what do you plan
to do for the pt on day 2? If
it changes, list the new one
in this column and provide a
rationale for the change
Thisdiagnosisremainsat#4.
Iwouldliketoinitiatea
consultwithapsychiatric
nurseaswellasmake
inquiriesaboutherpossible
optionsforadifferentcare
facility(shementioneda
facilitywhereshefeltbetter
caredfor).
 unsuccessfulinherattemptstogain
informationabouthertreatment
goalsanddischargeplans,
particularlyasitappliestothe
nursinghomewhereshecurrently
resides.Shefeelsignoredand
seemsresignedthatitisuselessto
attempttogaininformation.She
appearstohaveanexternallocusof
control.

ChronicSorrowr/t Patientexhibitsbehaviorsconsistent Thisdiagnosisstaysat#5.I
permanentdisability withthisdiagnosis.Shehasperiods wouldliketoexplorewith
ofsadness,crying,anger, thepatientherfeelingsabout
frustration,apathy,etc.Im counseling/medicationfor
concernedthatsheissufferingfrom depression.Iwonderifa
majorclinicaldepression. combinationofconsistent
cognitivebehavioraltherapy
andantidepressant
medicationmightpromote
readinessforenhanced
coping.


















25
MedicationOrder
fentanyl patch Duragesic
100 mcg transdermal q 3 days
Opioid analgesic
Anesthetic
MOA: may bind with opioid receptors
in CNS, altering both the perception of
and emotional response to pain
Patient is taking these types of meds
also list in another color or mark
with a highlighter!
Safe dose: 100 mcg per hour
zinc sulfate Zinca-Pak
220 mg PO daily
Trace element
Nutritional agent
MOA: participates in synthesis and
stabilization of proteins and nucleic
acids in subcellular and membrane
transport systems
Safe dose: 660 mg daily
enoxaparin sodium Lovenox
40 mg SC daily
Low-molecular-weight heparin
derivative
Anticoagulant
MOA: accelerates formation of
antithrombin IIIB-thrombin complex
and deactivates thrombin, preventing
conversion of fibrinogen to fibrin. Has
higher antifactor Xa-antifactor IIa
activity ratio
Safe dose: 40 mg SC once daily for 6-
11 days; up to 14 days can be
tolerated
lorazepam Ativan
0.5 mg PO 3X daily
Benzodiazepine, sedative hypnotic,
antianxiety agent, anticonvulsant,
skeletal muscle relaxant, antiemetic
MOA: inhibits ability to recall events.
Interacts with GANA-benzodiazepine
receptor complex in the brain
Safe dose: up to 10 mg daily
Rationaleforuseinthis NursingCareMeasures
patient
For pain relief
May interact with: CNS
depressants, other opioid
analgesics, diazepam (CV
depression may occur)
Side effects: confusion,
hallucinations, arrhythmias,
bradycardia, dry mouth, urine
retention, respiratory
depression, apnea
To promote healing of wounds
No significant interactions
Side effects: N/V
To prevent DVT, pulmonary
embolism
Side effects: peripheral
edema, CV toxicity,
hypochromic anemia,
thrombocytopenia,
hemorrhage, bleeding compli-
cations, redness/irritation at
injection site
To prevent/reduce anxiety
May interact with other CNS
depressants
Side effects: airway
obstruction, apnea, blurred
vision, confusion, crying,
delirium, depression,
excessive drowsiness,
hypotension, respiratory
depression, hypotonia,
1.Monitor bladder function, respiratory
rate and depth, and O2 saturation
2. Report respirations of <12/minute,
O2 sat of <95%
Notice that any teaching r/t
applying the fentanyl patch
has not been included -
patient is a quadriplegic and
unable to apply it herself.
Teaching would be directed
at family/caregivers, if
appropriate
1.Monitor serum zinc levels. Normal
range is 0.05 0.15 mg/dL
For severe overdose, give protamine
sulfate by slow IV infusion at
concentration of 1% to equal dosage
of enoxaparin injected
1.Monitor platelet count
2. To avoid drug loss do not expel air
bubble from 30- or 40-mg prefilled
syringes
3.Do not massage after SC injection.
Rotate sites among the L and R
anterolateral and the L and R
posterolateral abdominal walls
4.Monitor pt for s/s of bleeding
1.Monitor liver, kidney, and hematapoietic
function periodically
 Generic name not
capitalized
pantoprazole sodium Protonix
40 mg PO daily
Proton pump inhibitor, gastric acid
suppressant
MOA: inhibits the activity of the proton
pump by binding to hydrogen-
potassium adenosine triphosphate,
located at secretory surface of the
gastric parietal cells. Suppresses
gastric acid secretion
Safe dose: 40 mg daily x8 weeks
docusate sodium Colace
100 mg PO 2X daily
Emollient laxative
MOA: reduces surface tnsion of
interfacing liquid contents of bowel;
promotes additional liquid into stool,
thus forming a softer mass
Safe dose: up to 360 mg daily
ascorbic acid Vitamin C
500 mg PO daily
Water-soluble vitamin
MOA: stimulates collagen formation
and tissue repair; involved in
oxidation-reduction reactions
throughout the body
Safe dose: up to 500 mg daily for
patients with delayed wound healing
levothyroxine Synthroid
125 mcg PO daily
Thyroid hormone replacement
MOA: not fully defined; stimulates
metabolism by accelerating cellular
oxidation
Safe dose: up to 200 mcg daily
vancomycin HCl Vancocin
1 GM IV in NS q 12 hours
Glycopeptides
Antibiotic
MOA: hinders bacterial cell wall
synthesis, damaging bacterial plasma
membrane and making cell more
vulnerable to osmotic pressure
Safe dose: up to 1000 mg q 12 hours
(2000 mg daily)
To treat GERD
Side effects: headache,
insomnia, asthenia, migraine,
anxiety, dizziness, diarrhea,
abd. pain, constipation, urinary
frequency, UTI, back pain,
neck pain, bronchitis,
increased cough
To prevent/relieve constipation
Side effects: mild cramping,
diarrhea
To promote healing
Side effects: diarrhea, acid
urine, renal calculi
To treat hypothyroidism
Side effects: tachycardia,
palpitations, HTN, dysphagia,
To treat staph infection
(cellulitis of L upper thigh)
Patients specific
infection.
Side effects: tinnitus,
ototoxicity, nephrotoxicity,
wheezing, dyspnea, red man
syndrome
1.Monitor for signs of epigastric or
abdominal pain, and for blood in stool
or emesis
2. Tablet must be swallowed whole and
not crushed, split, or chewed
3.Give with or without food
1.Teach patient about maintaining
adequate fluid and fiber intake
1.Give PO solution directly into mouth or
mix with food
2.Teach patient about dietary sources of
Vitamin C
1.Monitor TSH levels
2.Give drug at the same time each day,
to keep hormone level constant
3.Instruct pt to immediately report chest
pain, palpitations, sweating, or
shortness of breath
IV Administration
Dilute in 200 ml NS
Infuse over 60 minutes
Do not infuse with any other medications
Always include instructions for
giving a med intravenously
1.Monitor peaks and troughs
2.Monitor site for phlebitis/irritation/
infiltration/extravasation
ampicillin sodium (1GM) and To treat skin structure infection IV Administration
sulbactam sodium (0.5GM) (cellulitis of L thigh) Reconstitute with: NS, D5W, or LR
Unasyn Allow to stand a few minutes to allow
1.5 GM IV q 6 hours Patient did experience vein foam to dissipate
Aminopenicillin and beta-lactamase irritation; because of my Inject over 10-15 minutes or dilute in 50-
inhibitor med research, I was 100 ml of a compatible dilutent and infuse
Antibiotic prepared for this possibility. over 15-30 minutes
MOA: ampicillin inhibits cell-wall See summary of pt status at Change site q 48 hours
synthesis during microorganism end of day 1. Do not add or mix with other drugs
multiplication; sulbactam inactivates
bacterial beta-lactamase, the enzyme
that inactivates ampicillin and provides Side effects: vein irritation,
bacterial resistance to it thrombophlebitis, anemia,
thrombocytopenia,
Safe dose: up to 3GM q 6 hours thrombocytopenic purpura,
(12 GM daily) leukopenia, agranulocytosis

oxycodone CR For moderate to severe pain 1.Monitor rate and depth of respirations; if
40 mg PO q 8 hours <12, report immediately
Opioid analgesic May interact with: other opioid 2.Give with food or milk to prevent GI
MOA: same as fentanyl analgesics (fentanyl) upset
3.Assess pain using a pain rating scale
Safe dose: up to 80 mg q 12 hours Side effects: hypotension, before and after administration
bradycardia, constipation,
ileus, urine retention,
respiratory depression

multivitamin Multivitamins are prescribed

1 cap PO daily for patients who need extra
Nutritional supplement vitamins, who cannot eat
enough food to obtain the
required vitamins, or who
cannot receive the full benefit
of the vitamins contained in
the food they eat

citalopram hydrobromide Celexa To treat depression 1.Monitor VS regularly for signs of

40 mg PO daily decreased BP or tachycardia
SSRI Side effects: confusion,
MOA: may enhance serotonergic tachycardia, dry mouth, taste
activity in CNS by inhibiting neuronal perversion, upper respiratory
reuptake of serotonin infection, increased sweating

Safe dose: up to 40 mg daily

28
MedicationOrder Rationaleforuseinthis NursingCareMeasures
patient

PRNs
diazepam Valium To treat anxiety or muscle 1.Monitor pulse and rate and depth of
1 mg PO q 6 hours prn spasms Respirations
Benzodiazepine 2.Report pulse <60 or respirations <12
Anxiolytic, skeletal muscle relaxant, May interact with: CNS
anticonvulsant, sedative-hypnotic depressants
MOA: may depress CNS at limbic and
subcortical levels of brain; suppresses Side effects: hangover, ataxia,
spread of seizure activity produced by psychosis, tremors,
epileptogenic foci in cortex, thalamus, bradycardia, CV collapse,
and limbic system diplopia, urine retention,
respiratory depression,
Safe dose: up to 40 mg daily desquamation

acetaminophen Tylenol As needed for discomfort or Antidote: acetylcysteine initially 140

650 mg PO q 6 hours prn fever mg/kg PO followed by 70 mg/kg PO q 4
Non-opioid analgesic hours for 17 doses
MOA: analgesic effects by blocking Side effects: neutropenia,
prostaglandins or pain receptor leukopenia, thrombocytopenia, 1.Carefully monitor all sources of
sensitizers liver damage, hypoglycemia, acetaminophen to ensure that
May relieve fever by acting in jaundice administration does not exceed 4000 mg
hypothalamic heat regulating center daily
Relieves pain and fever

Safe dose: up to 4000 mg daily

oxycodone HCl OxyContin For moderate to severe pain Nursing actions same as for oxycodone
10 mg PO q 4 hours prn CR
OR May interact with: CNS
5 mg PO q 4 hours prn depressants
Opioid analgesic
MOA: same as fentanyl, oxycodone Side effects: hypotension,
CR bradycardia, constipation,
ileus, urine retention,
Safe dose: 5 mg q 6 hours (20 mg/24 respiratory depression
hours)
This dose is not safe (pt may have
tolerance)








29
PRIORITYDIAGNOSES NURSINGINTERVENTIONS RATIONALES
ImpairedSkinIntegrityr/t Assess
immobility,pressureover 1.Site(s)ofskinimpairmentatleastoncedailyforsignsof 1.Systematicinspectioncanidentifyimpending
bonyprominences infection(colorchanges,redness,warmth,swelling, problemsearly
exudate,odor)
Citations not required in NUR 51
Subjective/Objectivedata:
Redness,moisture,broken 2.Patientscontinencestatus 2.Moisturefromincontinencecontributestopressure
skin,openareas,drainage ulcerdevelopmentbymaceratingtheskin

3.Nutritionalstatus(weight,calories,protein,CHO,fats, 3.Optimizingnutritionalintakeisneededtopromote
These are the s/s that you vitamins,minerals,prealbumin) woundhealing
directly observe or that
are reported by the
patient Prevent
1.Measuresizeanddepthofwound.Determinethat 1.Establishesabaselineforcomparisonwhenevaluating
impairmentinvolvesskindamageonly.ClassifyasStage healing
IorII

2.Minimizeexposureofskinimpairmentandotherareasto 2.Moisturecontributestopressureulcerdevelopmentby
moisturefromincontinence,perspiration,orwound maceratingtheskin
drainage

3.InitiateaPTconsulttoconductariskassessmenttoolto 3.AvalidatedriskassessmenttoolsuchastheNortonor
systematicallyassessimmobilityrelatedriskfactors Bradenscaleshouldbeusedtoidentifypatientsatrisk
forimmobilityrelatedbreakdownandtohelpguidethe
planofpreventionandcare

4.Avoidpositioningpatientonsiteofimpairment(coccyx) 4.Createspressureandinterfereswithperfusion

5.Turnandrepositionq2hours 5.Alternatessitesofpressurereliefandkeepsthepatient
 comfortable

6.Transferpatientwithcaretoavoidexternalmechanical 6.Preventsskindamage
forces(pressure,friction,shear)

7.MaintainHOBatlowestpossibledegreeofelevation 7.HavingHOBat<30degreesminimizesshearingof
tissuescausedbyslidingdowninbed

8.Useliftdevices,pillows,foamwedgestoassistpatient 8.Tomaintainalternativepositionsandpadbony
withmovingandpositioning prominences
Physicians specific
order for dressing 9.Applywoundgeldaily;packwith1rollofgauzeand 9.Physiciansorder.Promoteshealingandprotects
changes coverwithDSD wound

10.Avoidmassagingaroundwoundsitesandoverbony 10.Thiscanresultindeeptissuedamage
prominences

11.Identifythephaseofwoundhealing(inflammation, 11.Accurateunderstandingoftissuestatusprovidesa
proliferation,maturation) basisfordeterminingappropriatetreatments.

Expected outcome Evaluate
1.Patientwillregainintegrityofskinsurface

31
PRIORITYDIAGNOSES
RiskforInfectionr/topen Assess
wounds
Subjective/Objectivedata:
Elevatedtemp.,redness,
warmth,edema,prurulent
drainage,odor,abnormal
labvalues,positivecultures
Physicians specific
med orders, including
dose, route, and times
NURSINGINTERVENTIONS
1.Temperatureqshiftandprn
2.Forredness,warmth,edema,exudates,odor,elevated
temperature
3.Skinformoisture,texture,andturgor
4.Nutritionalstatus(weight,calories,protein,CHO,fats,
vitamins,minerals)
Prevent
1.Monitorlabvalues(WBC,differentials,prealbumin,
serumalbumin,cultures)
2.Washandthoroughlydryskin(pat,dontrub).Take
particularcarewithskinfolds
3.Encourageabalanceddiet.Emphasizeproteins,vitamins
(A,B6,B12,C,E),folicacid,linoleicacid,zinc
4.Give1tabletmultivitaminPOdaily@0800
5.Givezincsulfate220mgPOdaily@0800
6.AdministerVancocin1GMIVq12hours@0600/1800and
Unasyn1.5GMIVq6hours@0200/0800/1400/2000
RATIONALES
1.Elevatedtemperatureisasignofinfection
2.Theseareindicationsofinfection
3.Intactskinisnaturesfirstlineofdefenseagainst
microorganismsenteringthebody
4.Optimizingnutritionalintakeisneededtopromote
woundhealing
1.Labvaluesprovideaglobalviewofpatientsimmune
function
2.Maintaingsuppleskinisbestmethodforkeepingskin
intact
3.Thesenutrientsarerequiredforefficientfunctioningof
theimmunesystem
4.Physiciansorder.Promoteshealing
5.Physiciansorder.Promoteshealing
6.Physiciansorder.Treatsinfection
 7.Takemeasurestopreventnosocomialinfections(frequent 7.Hospitalacquiredinfectionsincreasemorbidityand
handwashing,steriledressingchanges,standard mortality
precautions)

8.Encouragefluidintake,ifnotcontraindicated 8.Fluidintakehelpsthinsecretionsandreplacefluidlost
duringfever
Evaluate
1.Patientwillbecomefreeofinfection

2.PatientsWBCcountwillreturntonormalparameters


RiskforIneffectiveTissue Assess
Perfusion,peripheralr/t 1.Calvesandthighsforredness,warmth,edema,venous 1.TheseareindicatorsofDVT
interruptedbloodflow dilation;alsocoolness,pallor,edemadistaltoinflammation
secondarytoprolonged
immobility 2.Pedalpulses 2.Absentordiminishedpedalpulsesindicatearterial
Ackley indicated
both active and insufficiency
Subjective/Objectivedata: Prevent passive ROM
Redness,warmth,edema, 1.PerformpassiveROMexercises only passive is 1.Toincreasecirculation,whichwillpromoteperipheral
listed due to pts
increaseincircumferenceof perfusion
quadriplegia this
calforthigh,absentpedal makes the
pulses,cool/paleextremity 2.Encouragedeepbreathing intervention 2.Increasesnegativepressureinthelungsandthoraxto
specific to the pt promoteemptyingoflargeveins,thusincreasing
peripheralperfusion

3.Measurecalvesandthighsdailywhilepatientissupine. 3.ToassessforextremityenlargementcausedbyDVT.
Monitorforincreasedcircumference Anincreaseof>2cmin1dayissignificant,aswellascalf

Powerlessnessr/tlossof Assess
function
Subjective/Objectivedata:
Crying,passivity,
irritability,guilt,
frustration,verbalizationof
havingnocontrol
diameter>3cmlargerthantheothercalf
4.Consultphysicianaboutuseofantiembolismstockings 4.CompressionstockingshelppreventDVTin
hospitalizedpatients
5.Increasefluidintaketoatleast23L/day,ifnot 5.Toreducehemoconcentration,whichcancontributeto
contraindicated developmentofDVT
6.GiveLovenox40mgSCdaily 6.Physiciansorder.PreventionofDVT
Evaluate
1.Patientwillmaintainadequateperipheralperfusionas
evidencedbynormalskincolor,temperature,andpositive
bilateralpedalpulses
1.Low:expressionsofuncertainty,passivity Itisnecessarytodeterminethelevelofpowerlessness
thepatientisexperiencingsothatthenursecanchoose
2.Moderate:nonparticipationincareordecisionmaking appropriateinterventions.
whenopportunitiesareprovided;resentment,anger,and
guilt;reluctancetoexpresstruefeelings;passivity; Thispatientexhibitsbehaviorsfromallthreelevels.
dependenceonothersthatmayresultinirritability;feeling
alienationfromcaregivers;expressionsofdissatisfaction
andfrustrationbecauseofinabilitytoperformprevious
tasks/activities;expressionofdoubtregardingrole
performance;doesnotmonitorprogress;doesnotdefend
selfcarepracticeswhenchallenged;inabilitytoseek
 informationregardingcare
3.Severe:verbalexpressionofhavingnocontroloverself
care,orinfluenceoversituation,orinfluenceover
outcomes;apathy;depressionregardingphysical
deteriorationthatoccursdespitepatientscompliancewith
regimen
4.Assessmyownphilosophiesofcaretoensurethatcontrol
issuesorlackoffaithinthepatientscapabilitieswillnot
biasmyabilitytointervenesincerelyandeffectively
Prevent
1.Bealertforbehaviorsthatattempttoassertpower,evenif
theyseemconfrontational.Assistpatienttochannelthose
behaviorsinaneffectivemanner
2.Determinethepatientslocusofcontrolrelatedtoher
health
3.Establishatherapeuticrelationship(spendoneonone
timewithher,keepcommitments,provideencouragement,
listenattentively,beempathetic)
4.Allowpatienttoshareherfeelings
5.Encourageparticipationinselfcareandselfmanagement
4.Professionalselfreflectionisanimportantelementin
themaintenanceofanempowermentphilosophy.Such
reflectionhelpsthenursecometotermswiththe
cognitivedissonanceoftryingtoempowerpatients
withinorganizations(healthcaresystem)thatare
inherentlydisempowering
1.Patientislookingforameasureofcontrol.Assisting
hertochannelherenergiesappropriatelyis
empowering.
2.Anexternallocusofcontrolcanleadapatientto
believethatshehasnopoweroverasituation
3.Powerlessnessisheightenedwhenthereisasenseof
distance,violation,ordisconnection
4.Listeningtothepatientreducesherfrustration
5.Themoreapatientparticipatesinherowncare,the
 ofillness.Haveherassistinplanningcarewhenever lesspowerlesstheyfeel
possible
Note the specificity
you would not place
6.Keepitemsthepatientneeds,wants,andisabletouse 6.Wellbeingcanbeaffectedmuchmorebychoices
the phone, food, or
drink within reach withinreach(tissues,calllight,televisionremotepatient relatedtoactivitiesofdailyliving.Patientisableto
because this patient is isabletouseherfingers) participateinherowncareifdevicesareaccessible
unable to move. She is,
however, able to grasp
items and use her 7.Giverealisticandsincerepraiseforaccomplishments 7.Givingrealisticpraiseassiststhepatientindeveloping
fingers positivefeelingsandenhancesselfconcept

8.Acknowledgesubjectiveconcernsorfears 8.Allfeelingsarepersonalandhavemeaningforthe
patient
Evaluate
1.Patientwillstatefeelingsofpowerlessnessandother
feelingsrelatedtopowerlessness

2.Patientwillparticipateinplanningandimplementing
care,andmakedecisionsregardingcareandtreatment
whenpossible

3.Patientwillverbalizehopeforthefuture








ChronicSorrowr/t Assess
permanentdisability 1.Forexpressionsofsadness,anger,beingmisunderstood, 1.Feelingssuchastheseareindicatorsofchronicsorrow
confusion,depression,disappointment,emptiness,fear,
Subjective/Objectivedata: frustration,guilt,orselfblame,helplessness,hopelessness,
Sadness,crying,fear, loneliness,lowselfesteem,beingoverwhelmed
verbalizationof
helplessness,hopelessness, Prevent
lackofappetite 1.Identifyproblemswitheatingorsleeping 1.Bereavedindividualshaveamoderateriskforpoor
nutrition

2.Spendtimewiththepatientanddevelopatrusting 2.Anempatheticpersonwhotakesthetimetolisten,
relationship offersupportandreassurance,recognizesandfocuses
onfeelings,andappreciatestheuniquenessofeach
individualishelpfultopatientsexperiencingchronic
sorrow

3.Helpthepatientunderstandthatsorrowmaybeongoing; 3.Studieshavedemonstratedthatfeelingsofsadness,
notimetableexistsforgrieving,despitepopularthought anger,frustrationandfearoccurperiodicallythroughout
thelivesofpeopleexperiencingchronicloss(this
Specify the patients womanisgrievingherlossoffunctionandprevious
loss
lifestyle)

4.Evaluatepreviouscopingskills 4.Helpsthenurseunderstandwhathashelpedthe
patientinthepastanddeterminewhethernewcoping
Does the pt have strategiesareneeded
family, friends,
5.Evaluatesupportsystems government/social 5.Helpsthenursetounderstandwhetherthepatienthas
services?
supportorwhetheradditionalresourcesareneeded

 6.Identifyavailablecommunityresources,includinggrief 6.Supportgroupscanserveasahelpfulmeansto
counselorsorsupportgroups improveinterpersonalcopingstrategies

7.Identifywhetherpatientisexperiencingdepression, 7.Counselingwiththerapeuticgoalsettinghasbeen
suicidalideation,orotheremotionaldisorders.Arrange showntobehelpful
forcounselingservicesasappropriate


Evaluate
1.Patientwillexpressappropriatefeelingsofguilt,fear,
anger,orsadness

2.Patientwillidentifyproblemsassociatedwithsorrow
(changesinappetite,insomnia,nightmares,decreased
energy)

3.Patientwillplanforthefutureonedayatatime

38
WhySuchLongCarePlans?
Youarenotthefirststudenttoaskthatquestion.Muchgrumblingand
complaininggoesoninregardtoBCCcareplans.Whileyoureuplateatnight
allyoucanthinkisThisisridiculous,Theyexpecttoomuchinformation,
Whysomanydetails?DoIreallyneedtoknowthis?andsoon,andsoon,
andsoon.Welcometonursing,theBCCway!
Iadmittoexperiencingawiderangeofnegativefeelingsaboutourcareplans;
Iwentsofarastowonderiftheinstructorsprimaryreasonforrequiringthemto
besodetailedandlengthywastotortureus!Imsureyouvehadoccasionto
feelthesamewayandifyouhavent,youwill.Well,letmeassureyouthat
thesefeelingsareborneoutofsheerfrustration(theyarentreallytryingto
tortureyou).Imetmanynurses,fromseveraldifferentschoolswho,upon
gettingalookatmycareplan,gleefullyinformedmethattheirswerenothing
likethat.Oh,howIenviedthem!Now,notsomuch.
Iamconvincedthatthesecareplansmademe(andwillmakeyou)abetter
nurse.Likeyou,Ioftenbelievedthatsomuchofthedetailedminutiaethatwe
wererequiredtolookupandunderstandwerewayaboveandbeyondwhatwe
neededtoknow.Clottingfactors?Myjobistogivethewarfarinandmonitor
prothrombintime;isntitthephysiciansjobtoworryaboutclottingfactors?
Betablockers,calciumchannelblockers,ACEinhibitors?Theyallcontrolhigh
bloodpressure,right?DoIreallyneedtoknowthedifferencesbetweenthem?
Imtryingtobeanurse,notapharmacist.Detailssuchasthesedrovemeto
heightsoffrustrationandresentmentthatsometimesmademequestionwhether
allthisworkwasworthit.Then,gradually,astrangeandwonderfulthing
begantohappen...Iknewwhatclottingfactorswereandwhichoneswere
targetedbywhatmedications,withouthavingtolookitup.Withoutabook,I
couldtellmypatientwhichclassofantihypertensiveheratenololwas,andhow
thatparticularmedicationworkstolowerherbloodpressure.Inadvertently,
almostwithoutmybeingawareofit,detailssuchasthesewereincorporatedinto
myknowledgebasethroughthetediumofhavingtoresearchthemoverand
overwhilewritingcareplans.Youwillresearchandwriteaboutsurgeries,
medicalconditions,laboratoryvalues,andmedicationssomanytimesyouwill
almostbeabletorecitetheminyoursleep.Asaresultofthis,youwill
eventuallycometoaplacewhereyouareabletosynthesizeallthisinformation
inyourheadandunderstandhowitalltiestogethertoaffectyourpatient.You
arelearningtocriticallythink.Theexhaustivenumberofhoursyouspendon
careplansare,minuteforminute,hoursofinvaluablelearning.Thoughyou

39
maybesittingathome,researchingandwriting,youareundoubtedlygrowing
inyourclinicalpractice.

LetmesaythatIdoubtyouwilleverenjoywritingacareplan.However,the
processwillbecomelesschallengingandtimeconsumingasyouadvance
throughnursingschool.Moreover,youwillfindyourselfontheclinicalunit
caringforyourpatientswithouthavingtoconsultyourcareplaneveryfive
minutes.Seeyourselfpracticingwithconfidence...thatiswhatyourcareplans
arepreparingyoutodo.

40
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
Section Four: Self Evaluations
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*

Afteryourclinicalweekisoveritwillbetimetoturnyourattentionto
completingyourselfevaluation.Thisisawritingintensiveexercisethatrequires
youtoreflectonyourclinicalexperienceandhonestlycritiqueyourperformance
asaproviderofcare,managerofcare,andmemberoftheprofession.Itisan
importantcomponentofyourlearningandatoolbywhichtomeasureyour
growthasapractitioner.Yourinstructorwillknowhowwellyouaredoingand
whatyourstrengthsandweaknessesarebyobservingyoueachweekasyou
interactwithpatientsandstaffinclinical;shewantstoknowwhetheryouknow,
andyourselfevaluationisthetoolsheusestodeterminethat.

Aselfevaluation(orselfeval,asitiscommonlycalled)isneverrightor
wrong.Youarenotgradedonit.However,itallowsyourclinicalinstructorto
understandyourlevelofselfawareness,aswellasyourinsightandjudgment,
whichwillbeconsideredasshepreparesyourendofcourseclinicalevaluation.
Asnurses,itisimportantforustoperformselfassessmentssothatweareaware
offeelingsandpotentialprejudicesthatmayaffectourpractice.Itis
unacceptableforapatienttoreceivelessthanoptimumcarebecauseourbeliefs
presentaconflictwhetheritbewiththeirpersonality,race,culture,religion,
sexualorientation,orlifestyle.Examiningourownskills,attitudes,andfeelings
issomethingweneedtodothroughoutthecourseofourcareers,sothatwecan
beconfidentthatweareprovidingthebestcarewepossiblycan.Donotmake
themistakeofthinkingthat,onceyouleavenursingschool,yourselfevaluation
daysareover.Verymuchtothecontrary,theyarejustbeginning.

Iencourageyoutoputyourbesteffortintopreparingthisdocument.Believe
me,Iunderstand,andempathizewith,thetemptationtorushthroughandleave
outimportantobservationsinanefforttojustgetitdone.Youretiredaftertwo
daysofcareplanningandclinical(onlittlesleep,mostlikely)andthelastthing
youfeellikedoingiswritingsomemore.Heck,youdontwanttothink
anymore;youwanttocomehomeafterthatsecondday,lieonthecouch,and
maybeindulgeinsomecomfortfood.Ifyourereallylucky,andthestarsareall
linedupjustperfectly,anap!TrustmewhenItellyouthatthereisntanursing

41
studentalivewhohasntfeltthatway.Heresmyadvice:ifyouhavetheenergy
andmotivation,thinkaboutandwriteyourselfevalrightaway,whilethedetails
ofclinicalarefreshinyourmind.However,ifbeingtiredmightcauseyouto
rushthroughit,donotwriteyourselfevalrightaway.Itsreallythatsimple.In
yoursecondyear,yourselfevalisduethemorningafteryoursecondclinical
day,withoutexception.Puttingitoffforafewhoursrestisnotdetrimental;you
arestillcompletingitbeforeimportantdetailshaveachancetoslipaway.In
yourfirstyear,however,youmayhaveafewdays,perhapseventheentire
weekenddependingonyourclinicalinstructor,beforeitisdue.Thesamerule
appliesastoafewhoursrest.Donot,however,putitoffformorethan24hours.
Waitinglongerthanthatmaycauseyoutoforgetdetailsaboutwhatoccurredin
clinical,nottomentionthatattemptingtowriteitatthelastminuteputsyou
rightwhereyoudontwanttoberushingtogetitdone.Ifyouabsolutelymust
putitoff,doyourselfafavorandatleastjotdownsomenotesforreference
regardingclinicalthatyouwanttoinclude.Iknowitisdifficulttobelievebut
youtrulycanforgetthings,ornotrecallthemasclearly,aslittleasonedayafter
clinical.Youretired,yourestressed,yourereadingtextbooksandhandouts,in
largevolumes,almostconstantly.Itisveryeasyforclinicaldetailstoget
crowdedout.
So,restabitifyouretired,butgetthatselfevaldoneassoonaspossible.

SampleSelfEvaluations
HereIhaveprovidedsamplesoffirstandsecondyearselfevaluations.They
areintendedtoillustrateforyouthecomprehensivenessanddegreeofdetailthat
isexpected.Youwillnoticethattheformatandcontentisabitdifferentforeach,
buttheunderlyingconceptremainsthesameforboth:toevaluate,inwriting,
yourclinicalskills.

42


 BCC
SelfEvaluation
NUR11&12

NursesRolesStudentComments InstructorComments
I.ProviderofCare
a.DataCollectionIamfindingthatdatacollectionbecomeseasiereachweek.AsI
growmorefamiliarwiththeKardex,medsheets,andthe
organizationofthechartIamabletolocatetheinformationIneed Your instructor knows that you
morequicklyandefficiently. collected and organized your
data she can see that on your
care plan. Here, provide some
b.DataOrganizationIamstillstrugglingtofindawaytoorganizemynotesmore
explanation about how the
effectively.Mydataiswellorganizedonmycareplan,butitseems process of collecting and
Iamspendingalotoftimesearchingthroughmynotestoaccessthe organizing was for you.
informationIwant,whichisdrawingoutthecareplanwriting
process.Iamhopingthat,withpractice,Iwillbeabletobetter
organizemynotetakingthinkingaheadtothetimewhen,asa
RegisteredNurse,mynoteswillbewhatIwillactuallyworkfromas
Icareforpatients.

c.Planningselected
approachesIplannedselectedapproachesaccordingtomyprioritydiagnosis,
whichwasRiskforInfection.IunderstoodthatIwouldneedto
observemypatientforanysignsofinfectionrelatedtohissurgical Evaluate how and why you
procedureandindwellingsuprapubicandFoleycatheters.In planned care as you did.
addition,Iplannedtocompleteathoroughskininspectionwhile
providingAMcare.Theseapproacheswereconsistentwithmy
identifieddiagnosis.

d.ImplementingIimplementedcareasplanned,withtheexceptionofperformingAM
care.Thepatientwasscheduledtobedischarged,thereforebathand
linenchangeweredeferredaccordingtohispreference.Ihadthe Were you able to implement care
opportunitytoperformsomeskillsIhadntplannedforsuchas according to your plan? Why or
discontinuinghisIVandcatheter.Itwasalittledisconcerting,asa why not? How did you feel about
student,tobeputonthespotthiswaybutprovidedexcellent working your plan?
practiceinlearninghowtoadapttochangesinyourplanofcare.

1.Procedures
(strengths&weaknesses)Ifeltmoreateaseperformingtheheadtotoephysicalassessment.I
amgrowingmoreconfidentwiththisskilleachweekbutrealizethat
thereisroomforimprovement.Wehavebeentaughttobeginour Describe and discuss any
assessmentatthetopandworkourwaydown,butIfindthatImstill procedures you performed.
Evaluate your accuracy and
forgettingsomethingsalongtheway,thenhavingtogobackand comfort level with honesty.
lookatanareathatIvealreadypassed.Thegoodthingaboutthisis
thatIamrememberingthatIforgotitinpreviousweeksI
sometimesdidntrealizethisuntilfillingouttheflowsheet.This
week,Irememberedwithoutneedingareminder.
IthinkIdidwelldiscontinuingthepatientsIVandFoley.Withthe
RNsguidance,Igatheredallthenecessarymaterialsforeach
procedureandremovedtheIV,andthenthepenilecatheter.Itis
quitedifferenttodothisonalivepersonthanitistodointhelab!So
asnottomakemypatientnervousorapprehensive,IactedlikeId
donethisahundredtimesbefore,whichwaschallenging,tosaythe
least.
Ihelpedthepatientdressandpreparefordischarge.Ispentalotof
timetalkingwithhimthroughoutthecourseofmyshift.IfeelI
displayedcompetenceinmostareastoday,notonlyincaringformy
ownpatient,butinassistingmyclassmateswhenneeded.Inotice
thatourabilitytoworkasateamseemstobeevolvingastheweeks
progress.Weassistandconsultoneanotherwithconfidence,more
secureinourclinicalknowledgebaseandpracticethanwewerejust
4or5weeksago.
MybiggestweaknessismonitoringI&O.Iamnotasdiligentabout
thisasIneedtobe.Imonitorandrecordtheoralintake,butI Be willing to admit to
neglecttheintakefromIVfluid.Inthisclinical,Ididnotrecordany weaknesses and mistakes.
output.WhenID/CdthepatientsFoley,theRNtookthebagaway When you identify a problem
toemptyit.Iforgottoaskheraboutthevolume,andthenforgotto area, discuss what you will
do in an attempt to improve
checkifithadbeenrecorded.Inordertoimprove,IthinkIllmake
I&Oaprimaryfocusfornextweek.
Consider your positioning. Did you
2.PhysicalsafetyIwasawareofphysicalsafetyatalltimes,bothmyownandthatof protect your back? Was the patients
mypatient. bed in its lowest position with the side
rails up? Did you practice standard,
3.BiologicalsafetyIworeglovesforallpatientcontact.Iwascarefultoavoidcross contact, and airborne precautions
when necessary?
contaminationbychangingglovesbetweenD/CofthepatientsIV
andD/CofhisFoley.

4.MedicationIfeltfineaboutresearching,retrieving,andadministeringmy
Administration/patientsmeds.Hespoketomeaboutnotwantingtotakehisiron,
Calculationbecauseitmadehimfeelsickandunabletoeat.Iconsideredhis
wishesandspoketohisnurseaboutwithholdingit,andthendidso,
indicatingsuchonhismedsheet.

5.OrganizationofcareIthoughtcarewaswellorganized.Althoughmypatientdidnot Did you feel you were organized?

requireclosemonitoringoragreatdealofphysicalcareitwasabusy Did you find yourself running
day.Mostofushelpedaclassmatecarefortheirpatientinsomeway around and rushing to get things
whenwewerentcaringforourown. done? What could you have done
differently?
6.ObservationsThemostimportantobservationImadetodaywashowwellwe
workedasateam.Inretrospect,Irealizedthatweeachwereconfident
aboutandfocusedonourindividualtasksbutfoundthetimetoask
forandgiveassistancewhenneeded.Incomparisontoourearlier
weeks,goneisthehesitation,fear,anduncertaintyaboutwhatis
requiredofusandhowwearetoproceedwithpatientcare.Post Include observations about
conferencealsoreflectshowwevelearnedandgrown,asweare anything you found interesting or
eachabletoprovideacomprehensiveyetsuccinctsummaryofour were able to learn from
patientsconditionsandthedaysevents.

7.Communicationskills/IPR
ChartingWiththeexceptionofI&O,aspreviouslymentioned,Ifeelfairly Was your charting clear, accurate,
confidentwhencharting.Imsurethereisroomforimprovement, and comprehensive while
remaining concise? How did you
whichwillcomewithpracticeandrepetition.Untilthen,Ijustask
feel about charting? How might
beforechartingifIamuncertainaboutsomething. you improve?

ReportingThisisgrowingeasierastheweeksgobyaswell.Iamgettingto
knowthenursesontheunit,andviceversa,andamdevelopinga
routineforconsultingwiththeRNpriortocare,andproviding
updatesthroughouttheshiftasnecessary.Theyaregoodabout
providinguswithinformationaswell,particularlyaboutprocedures
wemaywanttotakepartin.
Did you feel comfortable about
differentiating between what you
need/dont need to report? Was your
nurse receptive? Cooperative?

TeachingItaughtmypatienthow,beforestanding,heneedstosituponthe
edgeofhisbedforafewminutesinordertoavoidbecomingdizzyor
lightheaded.Iprovidedanexplanation,andthenhadhim
demonstrate.

EvaluatingIwasabletoevaluatemypatientsunderstandingbyobservinghis
abilitytofollowmydirections.Hewassuccessfulatassimilating
knowledgeregardingthecontentofmyteaching.

II.ManagerofCare
Seeksassistancefrom
appropriatehealthmembersAtthispointinclinical,Iamseekingoutmyclinicalinstructoror
primarynurseforassistancewhenneededandhavenotprogressed
toconsultingmembersofotherdisciplines.

III.MemberofProfession As a member of the profession, do

a.AgencyResourceManualsAlthoughIknowtheirlocation,Ididnotneedtoconsultresource you feel you are literate in the
community of nursing? Do you
manualsthisweek
understand how to find and utilize
resources, such as policy,
b.AgencyPolicies& procedure, and protocol manuals?
ProceduresIwasawareoftheprocedurestofollowforcarethatIprovided.I Do you feel that any knowledge you
understandthatIneedtoconsultwiththepolicyandprocedure obtained from the manuals helped
bindersifatalluncertainaboutthehospitalsprotocols. you grow as a member of the
nursing profession?

c.SelfEvaluationIbelievemyselfevaluationtobehonest,comprehensiveand
specifictothisweeksexperience. Evaluate your self-evaluation

IV.ProgramRequirements
a.AttendancePerfectattendancetodate
b.AssignmentsAllassignmentscompleteandsubmittedontime
c.MathExamPassedonfirstattemptwith95%
d.Participationinpre
andpostconferenceIbelievemyparticipationissatisfactoryandthatIampreparedto
discussandshareanyinformationpertainingtomypatient
assignment
e.AppearanceIaminuniform,whichiscleanandpressed,asrequired.
f.BehaviorAppropriateandconsistent.
g.VeracityBeyondreproach,asisexpected

 NUR51&52SELFEVALUATIONNAME:DATE:
Pleaseaddressthefollowingareasplusanyothersyouwishorneedtocommenton.UseEnd
OfCourseBehaviorsasguide.AddpaperPRN.
COMMENTS
PROVIDER(datacollection,NCP,worksheet,organization,
assessment,skills,revisions)
Iammostlysatisfiedwithmyperformanceintheseareasthisweek.I How was data collection? Did you
wasabletogatherallpertinentinformationonmypatientand encounter any difficulties? How
do you feel about your care plan?
organizeiteffectively.IreallyfeltlikeIunderstoodthispatient,what Did you struggle with it and, if so,
herneedswere,andwhatIneededtodotocareforher.Ifeltreally how and why? How did you feel
comfortableaboutreprioritizingafterinteractingwithherthefirst about working from your
worksheet? Do you prefer
day.Thishasbeenoneofmybestclinicalweeksasfarasmygrowth
working directly from your care
anddevelopmentasanurse.IfeltlikeIwasabletotakeinand plan?
synthesizenewinformationbasedonmyassessmentswithouthaving
todiginabooktoknowwhattodo.Mycareplan(finally!)feltmore
likeausefultoolratherthanaburden.Ibelieveitwasdetailedand
thorough,andmyrevisionsappropriate,andprovidedmewitha
usefulframeworkfromwhichtoprovidecare.Iambecomingless
attachedtomyworksheet,aswell.AlthoughItakeitoutoccasionally,
forremindersortojotdownnewinformation,Iamlessdependenton
it.Iamawareofcognitivegrowthtakingplace,asIamabletokeep
informationaboutmypatientinmyhead,aswellasassimilatenew
findings,andanalyzehowthingsalltietogether.
Myassessmentsarecarefulandthorough.Asastudent,Iamalways
afraidofthepossibilityofmissingsomething(andprobablywill
continuetobeasanurse).Forexample,Iworriedafterthefirst
clinicaldaythatIhadnotbeenabletolookatmypatientsIVaccess Be specific about
siteduetothebandagingthatcoveredit.Byday2,whenIcouldsee assessments or skills that
thatthebandagehadnotbeenchanged,Igrewveryconcernedabout you are discussing
thefactthatnoonehadlookedatheraccesssiteforatleast24hours.
Afterfirstgettingpermission,Iremovedthebandagingandwasable
toinspecttheareaanddeterminethatthesitewasnormalandtheIV
patent,muchtomyrelief.Myphilosophyisthatyoucanneverbetoo
careful.
Astoskills,Iwasabletolearnanddosomenewthingssuchas
hanginganIVbagandsettingthepumpandremovinganNGtube.I
wasdefinitelynervous,buttriedmybesttohidethatfromthepatient.
Ineedmorepracticeandimprovementwiththeseskills,naturally,but
nowthatIvedonethematleastoncetheyarenotsointimidating.

COMMUNICATOR(clarity,accuracy,useoftherapeuticinteractive
techniqueswithpts.,staff,charting)
IbelieveIamaneffectivecommunicator.Ilovetalkingwithmy
patientsandthusfarhavenothaddifficultyestablishingtrusting
relationshipswiththem.Ialwayslistencarefullytowhattheytellme
andtrytoadjustmytherapeuticinteractivetechniquestotheir
individualneeds.
Communicationwithstaffwasclear,beneficial,andbidirectional.I
learnedsomethingsaboutclarityandaccuracyontheflowsheetwith
thehelpofmyprimarynurse.Shetaughtmehowtochart
procedures/treatments(likediscontinuingtheNGtube)andhowto
putanasteriskbythenotationontheflowsheettoindicatethatIhad
writtenanursingnoteaboutit.

TEACHER(assessneed,provideexplanationanddemo)
Italkedwithmypatientabouttheimportanceofturningand
repositioningfrequentlyinordertopreventinfectionandskin You are always a teacher!
breakdown.AlthoughIassuredherthatIwouldcheckonheroften Dont ever leave this blank or
(becauseofherdiarrhea),Itoldherthatitwasimportantforhertouse say that you didnt teach
anything. Even if the patient
thecallbuttonifshemovedherbowelswhileIwasntthere,sothat
wasnt receptive, describe
herskinwouldnotbecomeirritated.Ialsodemonstratedcoughing what, and how, you attempted
anddeepbreathing,butwasmetwithconsiderableresistance,whichI to teach
feelwasduetoherinabilitytofocussecondarytohernauseaand
discomfort.

MANAGER(prioritizingfor2clients,delegating,interactingwithhealth
teammembers)
Ihadonlyaonepatientassignmentthisweek,andsodidnotneedto
prioritize,nordidIdelegateanycare.Ididapproachmyprimary Even if you do not have
nurseaboutthepossibility/feasibilityofgettingthepatientoutofbed more than one patient,
andwecollaboratedaboutinitiatingaPTconsult.Ultimately,we discuss how you managed
care on your own, or with
discoveredthattheMDhadalreadyorderedaPTevaluation.
other health team members
Nonetheless,Imgratifiedthatwewerethinkingalongthesamelines,
andhadadiscussionabouthowtobestapproachthisaspectofthe
patientscare.

MEMBER(legalethicalpractice;IDownstrengths/areastodevelop;seek
learningopportunities)
Ibelievemyselftobeaconscientiousproviderofcare,respectfulof, Try to be specific about what
your strengths and
andincompliancewithlegalandethicalguidelines.Mystrengththis weaknesses were this
weekwasmyabilitytosoothemypatientandcommunicate particular clinical week. As a
unconditionalpositiveregard.Shewasdistressed(andlikely member of the profession,
do you feel you are
embarrassed)aboutherexcessivediarrhea.Iwasabletohelpher improving in your own
relaxandassuredherthatitwasokayifshemadeamess,thatIwould practice and/or improving
berighttheretokeephercleanandcomfortable.Infact,Iencouraged nursing as a whole?
hertojustletitcomeandnottrytoholditback(notthatshecould).
Thismaynotseemlikeabigdealtoanordinary(nonnursing)person,
butasIleanedoverher,heldherhand,andlookedintohereyesasI
spoke,Icouldseeherreliefasheranxietymeltedaway.
Ineedtoworkonconsolidatingmycare.Itendtopacemyselfsothat
Idontendupbeingboredandfeelinguseless.Ireallyneedto
developinthisareabecauseIunderstandthat,asanursewithseveral
patients,Iwillnothavetheluxuryofdoingthis.IamconfidentthatI
willgetplentyofpracticeasmypatientassignmentgrowswiththe
progressionofthesemester.
Iamalwayseagertoobserveorparticipateinnewlearning
opportunities.ThisweekIgottowatchoneofmyclassmatesuse
steriletechniqueandchangeacomplicateddressing.

PROGRAMREQUIREMENTS(punctuality,prepandparticipationin
conference)
Ibelievemyperformanceintheseareaswassatisfactory.Ifeelthat
preconferenceprovidedanexcellentfoundationbeforemeetingthe
patient,andpostwasavaluableforumforevaluationofthedays
objectives.























50


AFTERWORD

Itismysincerehopethatthismanualwashelpfulinguidingyouthroughthe
careplanningandselfevaluationprocess.Itisimportantthatyouknowthat
thesewritingendeavorsareonlythebeginningofwhatwillberequiredofyouin
thenursingprogram.Thewritingassignmentswillgrowmorecomplexasyou
progressthrougheachsemester,requiringahigherlevelofthinking,
organization,andexpression.Learning,earlyon,howtowriteeffectivelywill
provideasolidfoundationforthechallengestocome.

Iencourageyoutotakeadvantageoftheservicesprovidedthroughthecolleges
WritingLab.Theirexcellentstaff,comprisedoffacultymembersandpeertutors,
canhelpyounavigateyourwaythroughanyphaseofthewritingprocess.In
addition,youwillfindwritingsamples,specifictothenursingprogram,thatyou
mayuseasmodelstoassistyouinsuccessfullycompletingyourownwriting
assignments.

If,afterreadingthismanual,youbelievethatIamaneffectivewriterand
successfulstudent,thenIthankyou.However,Iaskyoutorememberthatmuch
ofmysuccesswouldnothavebeenpossiblewithoutsomehelpalongtheway.I
havenotonlyhadtheprivilegeofworkingastutor,buthavehadthebenefitof
beingtutoredaswell,andthathasmadeallthedifference.Therehavebeen
tutorsatthiscollegewhohelpedturnwhatwassimplygoodworkintomybest
work.Iencourageyoutotakefulladvantageofthiscollegesmanyresources
particularlytutoringandwatchyourselfgrow,andbecomethemostsuccessful
studentyoucanbe.

51
 References

Ackley,B.J.,&Ladwig,G.B.(2006).Nursingdiagnosishandbook:Aguideto

planningcare.St.Louis:MosbyElsevier.

Carpenito,L.J.(2006).Nursingdiagnosis:Applicationtoclinicalpractice.

Philadelphia:Lippincott,Williams&Wilkins.

Fischbach,F.(2004).Amanualoflaboratoryanddiagnostictests.Philadelphia:

Lippincott,Williams&Wilkins.

Mosbysmedical,nursing,&alliedhealthdictionary(6thed.).(2002).St.Louis:

MosbyElsevier.

Potter,P.A.,&Perry,A.G.(2005).Fundamentalsofnursing(6thed.).St.Louis:

MosbyElsevier.

Springhousenursesdrugguide.(2006).Philadelphia:Lippincott,Williams&

Wilkins.

52
 AppendixA

BasicHumanNeedsandRelatedNursingDiagnoses

1.Oxygenation
Ineffectiveairwayclearance
Impairedgasexchange
Ineffectivebreathingpattern
Ineffectivetissueperfusion(specifyperipheral,cardiopulmonary,GI,renal,or
cerebral)
Decreasedcardiacoutput

2.Hydration
Deficientfluidvolume
Fluidvolumeexcess
Riskforimbalancedfluidvolume

3.Nutrition
Impairedswallowing
Selfcaredeficit,feeding
Imbalancednutrition(specifylessthanormorethanbodyrequirements)
Impairedoralmucousmembranes
Nausea

4.InvoluntaryRegulation
Delayedgrowthanddevelopment
Hyperthermia
Hypothermia
Ineffectivethermoregulation
Adultfailuretothrive

5.Elimination
Impairedurinaryelimination
Urinaryincontinence(specifyfunctional,reflex,stress,total,orurge)
Urinaryretention
Constipation
Diarrhea
Bowelincontinence
Selfcaredeficit,toileting

6.Safety/Security
Impairedtissueintegrity
Impairedskinintegrity
Riskforimpairedskinintegrity
Riskforinfection
Ineffectiveprotection
Riskforfalls
Riskforinjury

7.Comfort
Acutepain
Chronicpain
Fear
Anxiety
Chronicsorrow
Disturbedsleeppattern
Ineffectivecoping

8.Activity
Activityintolerance
Impairedtransferability
Impairedphysicalmobility
Impairedbedmobility
Deficientdiversionalactivity

9.Communication
Impairedverbalcommunication
Readinessforenhancedcommunication

10.Sensation
Disturbedsensoryperception(specifyvisual,auditory,kinesthetic,gustatory,
tactile,olfactory)
Acuteconfusion
Chronicconfusion

11.Selfesteem
Disturbedbodyimage
Ineffectivecoping
Disabledfamilycoping
Hopelessness
Powerlessness
Noncompliance
Situationallowselfesteem
Chroniclowselfesteem
Deficientknowledge
Sexualdysfunction
Socialisolation

12.Independence
Ineffectivehealthmaintenance
Deficientknowledge
Healthseekingbehaviors

13.Hygiene
Selfcaredeficit,bathing/hygiene
Selfcaredeficit,dressing/grooming
Impairedskinintegrity
Impairedoralmucousmembranes