NURS 1100 : CARE PLAN GUIDELINES

Information on writing care plans will be tested in two ways :

  1. Questions on quizzes / exams
  2. Use of the guidelines in your first care plan

LINKS

  1. Guidelines for writing Care Plans
  2. Guidelines for interviewing
  3. Gordon's 11 Functional Patterns
  4. Care Plan Part I
  5. Sample for Part I
  6. Grading criteria for Part I
  7. Care Plan Part II assignment
  8. Sample for Part II
  9. Grading criteria for Part II

 

GRADING CRITERIA FOR PART I

Turn in 2 copies of your care plan and keep the original.

For Part I of your first plan the scoring will be 20% for each of the following elements:

  1. General assessment of the client using Gordon's Patterns differentiates functional from risk areas
  2. Client selection is appropriate for assignment; contextual factors correctly separated from personal factors
  3. Nutritional assessment complete and correctly done. Includes physical observations.
  4. Conclusion (diagnosis) logical and well supported with evidence
  5. Presentation
  1. Presented according to instructions; college level scientific language; citations and bibliography appropriate
  2. Write formally : third person impersonal well expressed thoughts careful proofing.
  3. Use APA style in the body of the paper and in the bibliography.
  4. Hand in the paper on it's due date.
  5. Actually type the headings and sub headings in your paper :
GRADING CRITERIA FOR PART II

For Part II of your first plan the scoring each of the following elements will be:

15% Involvement of client in recognizing, planning, and resolving problems
10% Quality of diagnostic statement and evidence in Part I is attached to Part II.
Note: If you did not earn full credit for the diagnosis and data lists in Part I, improve them before attaching Part I to Part II.
10% Quality of 3-part goal statements
15% Nursing interventions effective, sufficient quantity, customized to client, and appropriate to goal.
15% Rationale for each intervention is scientific/ logical
15% Clarity of goal evaluation statement and conclusions
10% Quality of plan revision
10% Presented according to instructions; college level scientific language; citations & bibliography appropriate

You must do the following to get the presentation points:

  1. Write formally : third person impersonal well expressed thoughts careful proofing.
  2. Use APA style in the body of the paper and in the bibliography.
  3. Hand in the paper on it's due date.
  4. Actually type the headings and sub headings in your paper :

 

Guidelines for writing Care Plans in all Nursing courses

SELECTION OF CLIENT FOR CARE PLAN
  1. Follow the course assignment sheet in identifying appropriate clients.
  2. When you are in a course with a clinical lab, get the okay of your Clinical Instructor that a client is an appropriate choice for a Care Plan before leaving the clinical lab on the day you care for that client.
SUBMISSION DUE DATES
  1. Each care plan must state the dates of care plan submission and the date you gathered data on the client on the title page.
  2. When you have written a draft of your first Care Plan for any instructor it is suggested that you make an appointment to sit with her/him. Your instructor will check for major format errors, grouping of data into subjective or objective lists, and use of citations. Arrange the meeting well before your finished Care Plan is due. The advice can make a big difference in your grade but it does not guarantee an A on the Care Plan because the instructor will not check your logic, sense of priorities, language use, quality of the Overview section, or other details spelled out in these Guidelines.
  3. If you are unsure when any Care Plan is due, ask ! Points are taken off the grade of any assignment submitted after it's due date.
PRESENTATION
  1. Use a title page.
  2. Type the plan in outline format, not across the page in columns
  3. Proof it carefully. Typos and incorrect English reduce the grade. The Learning Center is happy to help students improve their written work.
  4. Write in third person, and in scientific, not casual, style.
  5. Use complete sentences for every part except the Data Lists.
  6. Use the Publication Manual of the American Psychological Association to write your citations.
  • Sources must be cited throughout the plan, as well as in a bibliography.
  • Quotation marks must be used when appropriate, always citing the page number. When restating an author's ideas using some of the same phrases the author used, also cite the page number.
  1. Submit 2 copies of your plan, but also keep a copy yourself.
  2. Use your last name as a running head in the upper right corner of each page, and number the pages.

 

OVERVIEW OF THE CLINICAL SITUATION
  1. Use initials for your client's name in the Overview and throughout the plan
  2. Introduce the situation, the significant persons involved and contextual factors that influenced your choice of priorities, and your approach to the problems.

NOTE: WRITE THE PLAN ONE DIAGNOSIS AT A TIME - FROM ASSESSMENT THROUGH EVALUATION.
For NURS 1100 you will be writing only one diagnosis.

ASSESSMENT DATA PATTERNS
1. Gather all data that leads you to a particular Nursing Diagnosis and its resolution and divide this information into two lists, Subjective Data or Objective Data.
2. Remove any information that is NOT directly linked to the one Nursing Diagnosis on which you are working.
3. In the Subjective Data list include relevant :
  1. client complaints
  2. description of the client's support system
  3. behavioral and nonverbal messages
  4. client awareness of her/his own
  • abilities / disabilities
  • disease process
  • prognosis
  • health care needs
  • available resources
4. In the Objective Data list include relevant:
  1. physical assessments including vital signs
  2. observations of the support system in action
  3. judgment of the client's readiness for learning, her learning potential, and locus of control
  4. chart information including lab and test results

 
NURSING DIAGNOSES
1. When writing a plan that includes several diagnoses, write the diagnosis with the highest priority first. In NURS 1100 you are to write only one Nursing Diagnosis for your first Care Plan.
2. A plan must start with the major issues for that client. For example, if the client is in acute distress over one problem, a plan covering only other minor problems would show lack of sensitivity on your part.
3. Select only diagnoses that are amenable to resolution by actions YOU can take.
4. Write out the three parts of the Nursing Diagnosis ( R.E.D. ):
  1. The human Response of the client [wellness response / problem ( anxiety)]
  2. Etiology or related events / factors, designated as R/T
  3. Data that is evidence of the diagnosis. You have already listed this information under Assessment Data Patterns, so say "as evidenced by the data listed above".

Note on related factors: Most human responses are related to several factors. List them all.

For example : anxiety related to

  1. new environment,
  2. separation from usual support system,
  3. big exam in two days

.

CLIENT GOALS
  1. Number each goal stating the client Goal, the Tool to measure   goal achievement, and the Time to evaluate [GTT]:
  2. The goal must be stated in terms of client achievement. ( for example : "The client will report a reduction in feelings of anxiety")
  3. Each goal must be measurable. You must indicate how you will measure if the goal has been achieved. ( for example : "as measured by the client assessing her/his anxiety as less on a 10 Point Anxiety Scale. It is now 7 on the 10-point scale.")
  4. Each goal must state a target date and hour for evaluation.( The Anxiety Scale will be re administered in 24 hours : date, hour.)
  5. Write at least one "short term goal" for every Nursing Diagnosis. This will demonstrate your ability to actually help a client achieve a goal. To get credit for the Evaluation section of your Care Plan set a time when you will be there to evaluate goal achievement. ( for example :" by noon today")
  6. Some goals that are important for your client are "long term goals". Write at least one "long term goal" for each Nursing Care Plan you develop. Your instructors understand that this kind of goal will have a time frame for evaluation that goes past the due date for the Care Plan. See the section on Evaluation on how to word the Evaluation of any "long term goal".
NURSING INTERVENTIONS WITH SCIENTIFIC RATIONALE
  1. Immediately following each goal that you write, list specific nursing actions you used to work toward that goal.
  2. Nursing actions must be specific, not global, appropriate, and without important omissions. In most cases several interventions are needed to achieve any one goal.
  3. If your idea to use a nursing action comes from a Care Plan book or other source, cite the source.
  4. After each nursing action give the scientific rationale for selecting the action. Cite your source for this rationale. Sources might include a book, lecture, discussion with a health professional or media source.
  5. Rationale must be logical and relevant.
EVALUATION OF THE PLAN
  1. State when you evaluated the goal. This should be the same time you designated in the Goal Statement earlier. (for example : " At noon 2/15/98")
  2. Use the measures you designated for goal achievement to state your client's degree of success. (for example : "the client evaluated her anxiety as 4 on a 10-point scale.")
  3. Draw conclusions on the interventions used related to the outcome. (for example : "Helping the client to talk about her feelings reduced her sense of isolation .")
  4. Consider changes or additions to the interventions that might improve goal achievement. (For example: "Studying with the client before the next examination should reduce her anxiety even more.")
  5. For the "long term goal" you write state: "Evaluation of this goal is set for (state the date & time). The client has made (no)(some)(significant)   progress toward this goal :  (describe any movement toward the goal)."