Professional Documents
Culture Documents
PC 4 Nursingcareplan
PC 4 Nursingcareplan
CRITERIA
INCOMPLETE
1 POINTS
POOR
2 POINTS
Assessment
Includes subjective, objective and
historical data that support actual or
risk for nursing diagnosis. Includes
pathophysiology of underlying disease
with reference from approved source.
Assessment portion
is incomplete.
Pathophysiology
portion is
incomplete.
Diagnosis
Includes the most appropriate nursing
diagnosis for patient that includes all
appropriate parts (stem, related to or
R/T, and as evidenced by AEB for
actual diagnosis) and is NANDA
approved.
Planning (Goal Setting)
Includes a patient or family goal that is
most appropriate for the patient/family
and the nursing diagnosis. Goal must
be reasonable, measurable, specific,
patient centered and have a target
time.
Implementation (Interventions)
Includes interventions or nursing
actions that directly relate to the
patient's goal, that are specific in
action and frequency, and include
rationale. Number of interventions
should be appropriate to help patient
or family meet their goal. Preferred: 3
clinical and 3 educational interventions.
Evaluation
Includes data that is listed as criteria in
goal statement. Based on this data,
goal is determined to be met, partially
met, or not met. If goal was not met or
partially met, student will provide an
explanation.
Diagnosis portion is
incomplete.
Goal portion is
incomplete.
FAIR
3 POINTS
GOOD
4 POINTS
Interventions
portion is
incomplete.
Evaluations portion
is incomplete.
Pathophysiology of underlying
disease
Assessment
Subjective Data: Patient states pain is 6/10.
Reports discomfort in his knee
Objective Data: Patient diagnosed with
staphylococcus arthritis (septic joint) of the right
knee. Arthroscopic surgery was performed on 4/21.
Knee is swollen, red, and warm.
Pertinent medical/surgical history: Gout,
Coronary Heart Disease, high cholesterol
Diagnosis/Planning
Nursing diagnosis: Chronic Pain related to inflammation of infected
joint as evidenced by septic joint.
Patient Goal: Get pain to a manageable level (less than 4)
Evaluation
Patients goal was met.
The patients pain scale at
the end of my shift was a
2/10.