Care Plan Format

APA title page – Running head and page number

Title
Your Name
Institution

Only include initials of the patient

Report Sheet – Main medical dx (reason for admission), Allergies, Code Status, Complete medical history, off going shift report (only
2nd quarter while at UT, head-to-toe assessment (1st quarter of school with staff, 2nd quarter @ UT)

Abnormal lab (Last month @ Shannondale, last 36-48 hours @ UT)

Medications (routine, PRNs in last 24 hours, IV’s (only @ UT)

Top three priority nursing diagnoses written out

Nursing diagnosis needs 3 interventions with rationales

Medical Diagnosis Sheet

Clinical Experience

Reference page – APA format

Each care plan is graded on the following criteria

Care Plan Rubric
Rubric Grading points Points Rationales
Medication Sheet due clinical week 1 10 points
Lab sheet due clinical week 1 10 points
Nursing Care Plan 3 total, one due each week 65 points
 Data 15 points
o Subjective
o Objective
 Nursing Diagnosis 10 points
o Identified appropriate nursing
diagnosis
o Three past nursing diagnosis
 Accurately Stated Goals (2 per RNDx) 15 points
o Realistic
o Specific
o Singular
o Time Frame
 Interventions (3 for each nursing 15 points
diagnosis)
o Independent Nursing Interventions
 Assessment Teaching
o Evaluations
 Tools for evaluation (return
demonstration)
 When to notify MD
o Dependent Nursing Interventions
 Ordered Diet
 Ordered procedures
 Ordered meds
 o Rationales 5 points
 Appropriate for
interventions
 Documented with source
and page number
 3 sources per nursing
diagnosis
o Evaluation 5 points
 Goals met or not met with
evidence
Medical Diagnosis due clinical week 3 10 points
 Concise (1-1.5 paragraph)
 Accurate
APA Sheet due clinical week 3 5 points
 Title Page
 Reference Page
 South College Report Sheet

-
Medical Dx: CVA Allergies: Aspirin (ASA), Codeine Phosphate
Namenda, Nuedexta, Remeron, Vitamin B12

Code Status: DNR

Hx: Dysphagia, Disorder of white blood cells, Muscle Weakness

Neuro: Alert and oriented x1, neck supple, nonfocal, GU: No abnormal findings
motor strength 3/5 upper and 2/5 lower extremities

EENT: PERRLA, conjunctiva is pink, sclera anicteric, MS: Full range of motion, no swelling or deformity
EOM full and normal, No significant lesions, no
erythema, no exudate, pharynx normal

Resp: Noted breathing sounds normal, no rales or Integumentary: No suspicious lesions, warm and dry
rhonchi, no costochondral tenderness

CV: Heart sounds S1,S2 normal, regular rate and Psychosocial: Mood/affect full range and normal
rhythm, no murmurs, no rubs, no gallops
GI: Bowel sounds present, full, soft, nontender, Tests/Procedures/IV: Labs
nondistended, no guarding, or ridgity, no masses,
palpable, no rebound tenderness, midline scar, PEG in
place

Patient Laboratory Findings

Patient initials _VM Date _10/31/2019

Date Labs ordered Normal values Patient’s value Individualized patient analysis
10/31/2019 Comp 3.5-5.7 3.1 Low albumin levels may represent
Metabolic/Albumin malnutrition and liver disease or an
inflammatory disease
10/31/2019 CBC w/Diff/RBC 3.90-5.03 3.85 Low RBC’s levels could represent
anemia or bone marrow failure
10/31/2019 CBC 0.0-11.7 13.5 High
w/Diff/Monocyte Levels of Monocytes may indicate the
presence of chronic infection, an
autoimmune or blood disorder,
cancer, or other medical conditions.
 Medication Sheet

Client initials VM Date 10/31/2019 Student LaDonna Moore

Allergies: Aspirin, Codeine phosphate, Namenda, Nuedexta, Remeron, Vitamin B-12

Medication Amount Frequency Safe range Mechanism of Major side effects Nursing interventions
(generic and /dose (if Action (How does (What should the nurse
trade name) applicable the medicine know about the medicine)
to the drug) work)
Docusate Sodium 10ml gastric Every 12 50mg/5ml It softens stool by Dizziness, Palpations, Expect long-term or excessive
liquid tube hours decreasing surface Abdominal cramps and use of docusate to cause
tension between oil distention, diarrhea, nausea, dependence on laxatives for
and water in feces. perianal irritation, vomiting, bowel movements, electrolyte
This action lets more muscle weakness imbalances, osteomalacia,
fluid penetrate stool, steatorrhea, and vitamin and
forming a softer fecal mineral deficiencies. Assess for
mass. laxative abuse syndrome.
1-tab gastric At bedtime 10 mg Reversibly inhibits Abnormal gait, agitation, Use cautiously in patients with
Donepezil Tablet tube acetylcholinesterase Abnormal ECG, chest pain, bladder obstruction because
and improves Pharyngitis, Hyperglycemia, drug’s weak peripheral
acetylcholine’s Abdominal pain, cholinergic effect could obstruct
concentration at constipation, Cystitis, UTI, outflow. Use cautiously in
cholinergic synapses. hemorrhage, muscle spasms, patients with asthma COPD, or
Raising acetylcholine Bronchitis, Ecchymosis, other pulmonary disorders
level in the cerebral Eczema, Dehydration, and because it has weak affinity or
cortex may improve Hyponatremia peripheral cholinesterase, which
cognition. Donepezil may increase
becomes less bronchoconstriction and
effective as bronchial secretions. Monitor
Alzheimer’s disease heart rate and rhythm for
progresses and bradycardia, which result from
number of intact increased vagal tone caused by
cholinergic neurons drug’s inhibition or peripheral
declines. cholinesterase. Take safety
precautions if patient is dizzy or
has other adverse CNS
reactions.
 6ml gastric At bedtime 250 mg/5 ml Is structurally like Agitation, Abnormal vision, The capsules may be opened
Gabapentin Solution tube gamma-aminobutyric Breast hypertrophy, and mixed with applesauce,
acid (GABA), the Abdominal pain, Acute fruit, juice, pudding, or water
main inhibitory renal failure, Anemia, before administration. Monitor
neurotransmitter in Arthralgia, Apnea, Alopecia, renal function tests, Monitor
the brain. Although Anaphylaxis client closely for evidence of
the exact mechanism suicidal thinking or behavior.
of action is unknown, Monitor client for
GABA inhibits the hypersensitivity. Do not exceed
rapid firing or 12 hours between doses on
neurons associated three times a day schedule.
with seizures. It also Give at least 2 hours after an
may prevent antacid.
exaggerated
responses to a
normally innocuous
stimulus to account
for its effectiveness
in relieving
postherpetic
neuralgia and restless
legs syndrome
symptoms.
12.5 mg Once a day 25 mg Inhibits reuptake of Abnormal dreams, Atrial Should not be given to clients
Sertraline Tablet gastric tube the neurotransmitter arrhythmias, glaucoma, with bradycardia, and it should
serotonin by CNS blindness, hyperglycemia, not be given to clients who are
neurons, thereby abdominal cramps, taking other drugs that prolong
increasing the anorexia, acute renal failure, the QT intervals. Expect
amount of serotonin agranulocytosis, aplastic hypomagnesemia and
available in nerve anemia, muscle cramps, hypokalemia to be corrected
synapses. An elevated coughing, alopecia, serum before sertraline therapy is
serotonin level may sickness, and weight loss begun. Monitor liver enzymes
result in elevated and BUN and serum creatinine
mood and reduced levels in clients with renal or
depression. This hepatic dysfunction. Be aware
action may also that effective antidepressant
relieve symptoms of therapy can promote
other psychiatric development of mania in
conditions attributed predisposed people. Watch
to serotonin closely for suicidal tendencies.
deficiency and Monitor closely for evidence of
premenstrual GI bleeding.
dysphoric disorder.
 South College Nursing Care Plan

Nursing Diagnosis Client Goals and Nursing Interventions, Rationale Evaluation

Alteration Nutritional Evidences with Source
Intake/Swallowing
relating to CVA as
evidenced by PEG tube
and parental feeding
 Subjective data:
Making non-
understandable noises

Objective data:
PEG tube
Temp 97.6 F, HR
58/min, BP 104/58 mm
Hg, RR 18/min
 South College Nursing Care Plan

Nursing Diagnosis Client Goals and Nursing Interventions, Rationale Evaluation

Expressive Aphasia Evidences with Source
relating to CVA as
evidenced by PEG tube
and parental feeding
 Subjective data:
Making non-
understandable noises

Objective data:
Exhibited effortful
speech
Temp 97.6 F, HR
58/min, BP 104/58 mm
Hg, RR 18/min
 South College Nursing Care Plan

Nursing Diagnosis Client Goals and Nursing Interventions, Rationale Evaluation

Dementia relating to Evidences with Source
CVA as evidenced by
being confused about
time and place
 Subjective data:
Making non
understandable noises

Objective data:
Client unable to recall
the time of day and her
location, facial
grimacing and smiling
Temp 97.6 F, HR
58/min, BP 104/57 mm
Hg, RR 18/min
 South College Department of Nursing
Medical Diagnosis Sheet

Write 1-2 paragraphs discussing the medical diagnosis, etiology, signs & symptoms, diagnostic tests, treatment, and complications.
 Clinical Experience

What did you do in your time here?

 Week 1: I was able to take care of a client with a PEG tube by giving her a bed bath. I also helped to feed several
clients during lunch time.
 Week 2
 Week 3
 Week 4

What lessons did you learn?

 Week 1: When giving a bed bath to a client with a PEG tube, it is very important that a nurse is informed to make
sure that the feeding is placed on hold and disconnected to prevent aspiration of the feeding. The nurse is responsible
for putting the feeding on hold. It is also important that the nurse flushes the tube before reconnection to loosen any
clogged feeding in the tube. The client should not be placed in the Sims position while the feeding is still running. It is
very important for the client to remain in the Semi-Fowler’s position throughout the feeding process.
 Week 2
 Week 3
 Week 4
 REFERENCES

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: diagnoses, interventions, & outcomes (9th ed.). St. Louis, MO:

Mosby, an imprint of Elsevier Inc.

Jones & Bartlett Learning. (2019). 2019 Nurses drug handbook (18th ed.). Burlington, MA.

Taylor, C., Lynn, P., & Bartlett, J. L. (2019). Fundamentals of nursing: the art and science of person-centered nursing care (9th ed.).

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