The "Down & Dirty" of Care Plan Requirements

A reference for you so that care plans are easier to understand

Analyze Assessment Data

ANALYZE (including validation) & CLUSTER data so pt prob can be ID
By Gordon s, by body system & by anything else that seems to go together

DIVIDE data -subjective & objective

Nursing Diagnosis
Once pt prob ID, nursing dx needs be made. Choose most approp nursing diagnosis(es)

Form correctly worded 3 PART NURSING DIAGNOSIS STATEMENT 3 Parts:

Problem/diagnostic label in NANDA terminology Etiology/Related Factors Support of the diagnostic statement/ defining characteristics

Nursing Diagnosis
`Must be a NANDA diagnosis `Clustering assessment data correctly reveals pt prob, which then translated into prob statement `Compare w/ definition & defining characteristics listed in NANDA text to validate your choice.

Etiology: Always Stated as R/T

Describes the process that is a contributing factor, but is NOT a cause & effect statement MUST BE TREATABLE! Cannot be the medical dx Cannot be a cause & effect statement Cannot be restatement of defining characteristics

Etiology: Always Stated as R/T

`Comes from one of following 4 categories:
R/T pathophysiology of the disease: biological or psychological R/T tx related effect R/T situational factor: environmental or pt R/T maturational factor: A contributing factor based on development of the pt

Etiology: Always Stated as R/T

NANDA text for possibilities MUST personalize to pt!

Support of Diagnostic Statement

Always stated as AEB (as evidenced by) Comes from defining characteristics (see NANDA book) Must be personalized to pt! These are clustering clues that got you to NANDA Dx

Putting It All Together

Example

`Fatigue `R/T Sleep deprivation from studying for exams in nursing school `AEB falling sleeping in class, loss of interest in usual activities, & verbal statements of student saying Im exhausted from school!

Goals & Expected Outcomes

Goals - non-specific desired outcomes Expected Outcomes Must Have: 4 parts Specific criteria which must be met

4 Parts of the Expected Outcome

A SUBJECT (the pt) An action VERB (will .) A PERFORMANCE CRITERION (what you want to see) A TARGET TIME (when you want to see it)

Criteria for Expected Outcomes

Must meet 4 part criteria Must also be:
Client centered Singular in goal Observable Measurable Time limited Realistic Mutually agreed upon

Expected Outcome Statement

` The student (subject) will sleep (verb) at least 6 hours per night (performance criteria) during this semester (target time)

`Is it:
x Client centered? x Singular? x Observable? x Measurable? x Time Limited? x Realistic? x Mutually agreed upon?

Interventions
5 parts in intervention statement
(Must include them all to be accurate)

Action Frequency Quantity (if applicable) Method Person to perform them APFQM

Interventions
Example:
The instructor (person to perform) Will schedule (action) each unit exam monthly (frequency) so that it does not overlap w/ another instructors exam (method)

Interventions in Student Care Plans

Each intervention must be accompanied by a SCIENTIFIC RATIONALE Look in NANDA book & textbooks to find

Evaluation
Met? Partially met?
State how.

Unmet?
State why.