Nursing Care Plan Template

In the care plan template provided, identify 4-6 actual or potential physiological patient problems.

Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).

  • This should be specific assessment data e.g. SBP 88mmHg instead of just saying ‘hypotensive’

Identify the optimal outcome that your patient should achieve before they are discharged.

  • This should be a specific target that is appropriate for your specific patient e.g. SBP 110-130mm/Hg, urine output > .5mls/kg/hr, GCS 15/15, etc.

Do not include nursing interventions in the template.

Problems may be:

•   actual health problems: a health problem that is currently present or occurring and needs intervention to either end or reverses its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.

Examples:     Dehydration due to ……..

Wound infection related to ……

Acute pain related to ….

Impaired skin integrity due to ….

Inadequate tissue perfusion related to……..

•  potential health problems: a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.

                                The patient is ‘at risk of’ falls due to …

                                The patient is ‘at risk of’ developing a  DVT due to….

The patient is at risk of infection due to………

For potential health problems, please consider that you are identifying the risk based on evaluation of the data you have been given in the case study. As such, the assessment data will be what puts the patient at risk rather than the assessment data the patient would have if they had this problem as an actual problem. For example, the assessment data for an actual DVT will be redness, swelling, pain, heat while the assessment data for a potential DVT might be reduced mobility, low BP, activation of inflammatory response.

Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.

Actual or potential problem     

Assessment data                         

Nursing outcome

Actual problem: the patient is dehydrated related to decreased fluid intake

  • Low blood pressure (or ↓BP) – SBP 88mmHg
  • Tachycardia – HR 125bpm
  • Patient states he is thirsty
  • Dry mucous membranes
  • Low urine output – 100mls in 6 hours
  • Patient will return to a normotensive state with a systolic BP between xx and xxmmHg
  • HR will be between x and x
  • Lack of reported thirst
  • Moist mucous membranes evident.
  • Urine output will be at least xmls/hr

The patient is ‘at risk of’ infection due to compromised host defences

  • Low neutrophil count
  • Receiving radiation therapy for cancer
  • Pt will remain free from any nosocomial infection
  • WCC will remain between and x
  • Pt will verbalise how to prevent acquiring infections
  • Pt’s family, friends, and hospital staff will use appropriate infection control include PPE and HH

Note: you can use commonly used abbreviations or symbols, e.g. BP for blood pressure.

No marks are allocated to the template, however it is required to be submitted in order to receive a pass grade for this assessment.

Nursing Care Plan Report – 2000 words

From your nursing care plan template select 2 (two) physiological problems. These may be actual problems, potential problems or one of each.  Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these and they will not be marked.

For each of your chosen problems:

  • Explain the pathophysiology and how this relates to the patients clinical presentation. I.e. What is happening in the body to cause the signs and symptoms that the patient has?
  • Identify the key nursing interventions required specifically to treat or prevent the problem you have chosen. These interventions should be supported by contemporary clinical guidelines, policies and high quality best-practice evidence. Nursing interventions should include a rationale supported by evidence. Nursing interventions may be
  • Independent interventions – nurse led, nurse initiated
  • Collaborative interventions – with other members of the multidisciplinary team
  • Dependant interventions  – for example dependent on a doctors order
  • These interventions should focus just on interventions which will specifically treat or prevent your chosen problems. Please do not include general nursing care which would be applicable here, or interventions which are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it). 
  • Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?
  • Include specific outcomes here appropriate for your patient. The idea is that if someone were to read your plan of care without knowing the patient they would still be able to achieve patient specific goals. For example, your patient might have a history of COPD with CO2 retention and the target oxygen requirements would be 88-92%. Instead of your outcome being ‘satisfactory oxygen saturations’ you should specify ‘oxygen saturations of 88-92%’. Instead of saying “acceptable BP” as an outcome, identify what range you want the BP to be in for your patient.

 As this is a formal academic report you should include

– an introduction: identify which patient case study you are using and the purpose/direction of your report e.g. “… This report will discuss compartment syndrome and surgical wound breakdown as two actual problems experienced by Mr. Smith. The pathophysiology of these conditions will be outlined along with nursing interventions required to treat these problems…”

– a conclusion: 1 or 2 sentences only which sum up your work. The conclusion should not include references as it is a summary of your ideas only. 

– at a third year BN level, for a 2000 word report you should have at least 20 high quality sources of evidence

92440 Complex Nursing Care Medical Surgical (Summer session)
Marking Criteria: Assessment 1 Complex patient plan of care and individual written report.

MARKING CRITERIA – Individual Written Report (weighting: 50%)

Criteria High Distinction (>85%) Distinction (75-84%) Credit (65-74%) Pass (50-64%) Fail (<50%)

Identification of 2 actual or
potential health problems
from the plan of care with
evidence of correlation with
assessment data and
relevant pathophysiology.
Plan of Care provided as an
appendix (25%)

Highly accurate and
researched links made
between assessment data,
pathophysiology and the
identification of health
problems.

Evidence of accuracy with
researched links made
between assessment data,
pathophysiology and the
identification of health
problems.

Evidence of researched links
made between assessment
data, pathophysiology and
the identification of health
problems. At times needs
further detail or correlation.

Limited development in the
links made between
assessment data,
pathophysiology and the
identification of health
problems. However requires
further research and needs
greater detail or correlation.

Lack of evidence of links
made between assessment
data, pathophysiology and
the identification of health
problems. Requires much
further research and greater
detail and/or demonstration
of understanding.

Marks (/100) 21.5-25 19-21 16.5-18.5 12.5-16 0-12

Identification and
development of
appropriate rationalised
nursing interventions.
(20%)

Interventions are
appropriate and have a
strong, well-researched
rationale which
demonstrates a high level of
accuracy in data
interpretation.

Interventions are
appropriate have research
based rationales which
demonstrates accuracy in
data interpretation.

Interventions are mostly
appropriate and have
research based rationales
which demonstrates
appropriate data
interpretation. At times
needed further depth and
detail.

The appropriateness of the
intervention is variable.
Rationales which
demonstrate data
interpretation. However
work needs to demonstrate
a greater depth of
understanding and detail.

Interventions are
inappropriate or lack
rationales such that data
interpretation is not
accurate.

Marks (/100) 17-20 15-16 13-14 10-12 0-9

Explanation of intended
patient outcomes and how
the effectiveness of the
nursing interventions would
be evaluated/measured
(20%)

Each intervention has a
highly relevant and well
researched expected
outcome and the evaluation
of this outcome is accurately
discussed.

Each intervention has a
relevant and researched
expected outcome and the
evalu

Mrs Allegra Thomas

• Location: Medical ward

• Introduction

• 86yr old female Allegra Thomas was admitted 5 days ago following referral from her GP.

• Situation

• Admitted with electrolyte imbalance, dehydration now improved with IV 0.9% NS over the past few days but

has become increasingly confused again over the last hour.

• Background

• Her daughter Nina took her to the GP after finding her on the floor at home (unwitnessed fall) with

confusion and lethargy. No major injuries noted, small bruise to L) knee. Allegra stated she had been on the

floor for 11 hours, she was dehydrated and blood tests showed hyponatraemia on admission.

• PMH: Hypertension, T2DM, previously high cholesterol, now within normal limits since her husband died, nil

medications for this. NVDx2.

• Drugs: Metformin 1g TDS, Ramipril 5 mg OD (withheld at present)

• Allergies: Bee stings

• Social: Lives alone. Widowed for 3 years. 2 adult daughters, Nina (a retired chemical engineer) lives nearby,

Ella (a seismologist) lives in NZ.

• Assessment/Observations

• A – patent. Talking in complete sentences

• B – RR 21, shallow. Sp02 93% on RA, bilateral equal air entry clear but muffled bases.

• C – HR 121, SR, BP 96/63, CRT 3 secs, cool peripheries, pale

• D – GCS 14 (E4, V4, M6). Confused to time and place, PEARL, Pain 1/10 at L) knee, nil other pain reported.

• E – IVC looks inflamed and red. Painful to touch. Appears a bit shivery. Temp 38.2. Small bruise still visible on

L) knee, nil broken skin.

• F – IVF continue at 80mls/hr. Poor oral intake since admission. FBC shows – +ve balance over last 12 hours.

Urine output 150mls, once over previous 8 hours. Bowels opened yesterday, formed.

• G – BGL 15mmoLs, Ket. 0.0

• Investigations & results

• FBC – WCC 17.3, Hb 117, Platelets 253

• U&E’s – Na 136, K 3.8, Cr 132, HCO3 19.4, Glucose 15.6.

• CXR – minor bibasal atelectasis, improved from admission CXR

• ABG – pH 7.22, PaCO2 40, PaO2 68, HCO3 18, BE –3.2

• Lactate – Lactate 3mmol/L

PLAN OF CARE

PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED

PATIENT ASSESSMENT DATA

OPTIMAL PATIENT OUTCOME or GOAL

Patient problem/issues/need – which is related to <insert>

Patient problems/issues/needs can be actual present and occurring now

Or potential when the patient is considered to be
‘at risk of’.

As evidenced by (or how do we know this problem exists)

Objective patient data

Subjective patient data

Lab and other test results

What do we (patient and nurse) want to achieve:

Specific, measurable, attainable, realistic and time orientated (SMART goals)

1.


2.

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4.

5.

6.

One row per problem

Up to 6 prioritised problems (minimum 4)