-Fill out each section of the care plan for privacy and HIPAA concerns, do not place any identifying information such as Name, DOB, phone number, MRN/EHR #, etc.
-Fill out the entire nursing care plan form, but if there is no data to support a section, place an “NA”. Under Abnormal labs/diagnostics, include information pertinent to the patients current problems. For example, increased GFR due to trauma related to falls or abnormal CXR with infiltrates in the right lung from aspiration pneumonia. Explain why you think that the lab value is abnormal as it relates to the patients current problem.
-For the H&P section, summarize a brief synopsis of the patients significant history, current problems, and admitting diagnosis. A good place to find this information is usually in the admitting/ER consults doctor’s notes.
-All documentation (references and citations) will be done in the current 7th Edition APA format. Will not accept references from Wikipedia, Nurselabs.com, or any site that is of a private opinion. It must be vetted and verified by trusted sources such as peer-reviewed journal articles, published Journal sites, or government sites such as the National Institutes of Health (NIH) or the Centers for Disease Control and Prevention (CDC). Also accepted are accrediting bodies (Joint Commission, CCNE, ANA) or published books.
IMPORTANT ASPECTS OF A CARE PLAN:
- Assessment Data
- Reason for visit
- Comorbidities
- Medications related to illness
- Laboratory, diagnostic results
- Nursing Care Plan
- Nursing Diagnosis (at least 3) (NANDA-I)
- SMART Goals for that shift, interventions, rationales (between 2-3)
- Evaluation (Met or Not Met and why)
- References/APA format/Spelling/Grammar
- See the Care Plan Rubric below
- Utilized your Carpenito Nursing Diagnosis: Application to Nursing Practice, 15th edition
Remember to use your resources when you do this, such as your nurses and doctors, and talk to the patients to better understand why they are there from their perspective. Remember, you are to learn and interact with as many people as possible while you are on rounds at the hospital.
Use SMART Goals, interventions, rationales, and evaluations that can be measured within a shift. Also, remember, don’t make a care plan complex. Please keep it simple. In the real nursing world, our care plans are simple, easy to understand, and easy to implement. As always, reach out to me with any questions.
Warning: Use of any AI-assisted programs, such as ChatGPT, is prohibited when generating your care plan. If you are suspected of using these programs, you will automatically be under review for possible loss of admission to the course and possibly removed from the nursing program, as this is covered under the student code of conduct for cheating and plagiarism. These care plans are individualized plans you make for your patient.
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