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 x 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
