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    Nursing Care Plan and Sample Outline

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    kpop fever
    1. The document outlines the ADPIE process for developing a nursing care plan, which includes assessment, diagnosis, planning, implementation, and evaluation. 2. It describes the three types of nursing diagnoses - risk, actual, and health promotion - and provides examples. 3. Directions are given for how to start the care plan, including how to form a nursing diagnosis, goal, and interventions. Samples of each are shown.

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    Nursing Care Plan and Sample Outline

    Uploaded by

    kpop fever
    112 views2 pages
    1. The document outlines the ADPIE process for developing a nursing care plan, which includes assessment, diagnosis, planning, implementation, and evaluation. 2. It describes the three types of nursing diagnoses - risk, actual, and health promotion - and provides examples. 3. Directions are given for how to start the care plan, including how to form a nursing diagnosis, goal, and interventions. Samples of each are shown.

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    1. The document outlines the ADPIE process for developing a nursing care plan, which includes assessment, diagnosis, planning, implementation, and evaluation. 2. It describes the three types of nursing diagnoses - risk, actual, and health promotion - and provides examples. 3. Directions are given for how to start the care plan, including how to form a nursing diagnosis, goal, and interventions. Samples of each are shown.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    112 views2 pages

    Nursing Care Plan and Sample Outline

    Uploaded by

    kpop fever
    1. The document outlines the ADPIE process for developing a nursing care plan, which includes assessment, diagnosis, planning, implementation, and evaluation. 2. It describes the three types of nursing diagnoses - risk, actual, and health promotion - and provides examples. 3. Directions are given for how to start the care plan, including how to form a nursing diagnosis, goal, and interventions. Samples of each are shown.

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    BEAUTIFULNURSING CAREPLAN

    Before you begin your care, it is important to remember ADPIE.


    A: Assessment
    Assessment is collecting subjective and objective data from the patient and secondary sources. ex: Vitals
    D: Diagnosis
    Diagnosis is identifying the patient’s problems and priority of care.
    There are three types of diagnosis: RISK, ACTUAL and HEALTH PROMOTION nursing diagnosis.
    Risk: the patient is at risk for developing _____ because of health conditions/life processes/etc.
    Actual: The patient has ____ because of health conditions/life processes/etc. It is not a risk because they have it.
    Health Promotion: a clinical judgement of motivation, desire to enhance wellbeing of patient.
    P: Planning
    Planning is setting goals of care and desired outcomes that will be appropriate to prevent, manage, or
    enhance the patient’s condition.
    I: Implementation
    Implementation is performing the nursing actions identified in the planning. These should directly correlate
    to the goals.
    E: Evaluation
    Determine if the goals were met or not. If not, the patient may need to be reassessed and a new priority plan
    or care should be established.

    HOW TO START

    Forming a Nursing Diagnosis:


    1. The problem/nursing diagnosis from NANDA.
    2. Etiology of related to “r/t”
    3. Symptoms “AEB”

    Example: Acute Pain r/t tissue trauma AEB pain level of 9 on 1-10 scale and winces in pain.

    Forming a Nursing Goal:


    They should be SMART and correlate with the nursing diagnosis.
    S: Specific
    M: Measurable
    A: Attainable
    R: Realistic
    T: Time framed.

    Example relating to nursing diagnosis above.

    Ex: Patient will verbalize a decrease in pain by rating less than 5 on 1-10 pain scale within 24 hours of receiving pain medication.

    Forming a Nursing Intervention:


    Nursing interventions are treatments or actions that will benefit the patient to meet the goal as stated previously. Interventions can either be nurse
    initiated (done by nurse) or collaborative (done as a team effort with other health care professionals).
    These interventions should be EB (evidence-based) and there are many great examples in the NANDA book.

    Examples: Nurse will assess the patient’s pain level Q2 hrs. while patient is awake, nurse will administer ____ per md instructions to decrease
    pain levels, nurse will educate patient on how to prevent or manage pain with 4 nonpharmacological techniques, nurse will reposition patient Q2
    hours to increase comfort of patient.
    NURSING DIAGNOSIS #1
    PRIORITY

    Diagnostic Statement:

    Intervention: What treatment Implementation: What


    or actions are you going to actions did you perform to
    use? carry out the plan of care?

    R/T: Intervention #1 Implementation #1

    AEB (symptoms, not used if


    Intervention #2 Implementation #2
    risk diagnosis):

    Justification for
    Prioritization (Use Safety, Intervention #3 Implementation #3
    ABC’s, Maslow’s)

    Outcome- Make it SMART! Evaluation (Did it work or not? Why not?)

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