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    2018 5-4 Care Planning

    Uploaded by

    Ed Schnurnberger
    This document outlines the steps for creating a care plan, including gathering subjective data from the patient, clustering symptoms and identifying nursing problems, prioritizing problems, setting goals and expected outcomes, planning interventions and evaluations, considering relevant diagnostic results and vital signs, anticipating complications, monitoring for improvement or worsening, ensuring discharge education priorities are met, and engaging with the patient's experience.

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    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd

    2018 5-4 Care Planning

    Uploaded by

    Ed Schnurnberger
    38 views4 pages
    This document outlines the steps for creating a care plan, including gathering subjective data from the patient, clustering symptoms and identifying nursing problems, prioritizing problems, setting goals and expected outcomes, planning interventions and evaluations, considering relevant diagnostic results and vital signs, anticipating complications, monitoring for improvement or worsening, ensuring discharge education priorities are met, and engaging with the patient's experience.

    Original Description:

    Nursing care plan form

    Original Title

    2018 5-4 Care Planning (3)

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    This document outlines the steps for creating a care plan, including gathering subjective data from the patient, clustering symptoms and identifying nursing problems, prioritizing problems, setting goals and expected outcomes, planning interventions and evaluations, considering relevant diagnostic results and vital signs, anticipating complications, monitoring for improvement or worsening, ensuring discharge education priorities are met, and engaging with the patient's experience.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    38 views4 pages

    2018 5-4 Care Planning

    Uploaded by

    Ed Schnurnberger
    This document outlines the steps for creating a care plan, including gathering subjective data from the patient, clustering symptoms and identifying nursing problems, prioritizing problems, setting goals and expected outcomes, planning interventions and evaluations, considering relevant diagnostic results and vital signs, anticipating complications, monitoring for improvement or worsening, ensuring discharge education priorities are met, and engaging with the patient's experience.

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    © All Rights Reserved
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    You are on page 1of 4

    CARE PLANNING AND CLINICAL REASONING

    Plan of Care
    Subjective Data: What did patient say? Use direct quotes. (abnormal) (Comes from patient and/or significant others)
    Cluster significant data by 3 concepts and assign a Nursing Problem to each:
    Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

    Step 2: Identify Concept that data describes

    Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

    Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

    Step 2: Identify Concept that data describes

    Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

    Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

    Step 2: Identify Concept that data describes

    Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

    Clinical Reasoning:
    1. List nursing problems from highest priority #1 to lowest priority #3 based on your clustered data, concepts, and
    problems identified above:

    1. _____________________________________________________________________________________
    2. _____________________________________________________________________________________
    3. _____________________________________________________________________________________
    2. Based on your patient’s current status, what problem concerns you the most at this moment in time and
    why?

    Rev. 2018 5-4 1


    Collaborative Nursing Care

    3. Based on this priority, what is your goal for this patient?


    _______________________________________________________________________________________

    4. Based on this priority plan your care for this patient:


    Expected Outcomes: Nursing Interventions: Rationales: Evaluations:

    5. What diagnostic results are relevant and clinically significant? List and give significance.

    6. What Vital Sign(s) data are relevant and clinically significant? List and give significance.

    Rev. 2018 5-4 2


    7. What is the most likely complication to anticipate? What assessment should you make? What
    intervention(s) should you do?

    8. When evaluating the patient, how will the nurse know the patient is getting better or worse?

    9. Did your patient achieve the goal set for them? If not, what revisions in care

    Education Priorities/Discharge Planning


    1. What will be the most important discharge/education priorities you will reinforce with their medical
    condition to prevent future readmission with the same problem?

    Rev. 2018 5-4 3


    2. How is the effectiveness of the teaching assessed by nurse?

    Caring and the “Art” of Nursing


    1. What is the patient likely experiencing/feeling about their current state of health/hospitalization?

    2. What can you do to engage yourself with this patient’s experience, and show they are important to you
    as a person?

    Rev. 2018 5-4 4

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