Registered Nursing Program
NURS 260 Medical-Surgical Nursing Across the Lifespan
Care Plan
Objectives:
1. Demonstrates effective communication with patients across the lifespan through therapeutic communication techniques, active listening, and appropriate terminology. (CLO 3)
2. Demonstrates confidentiality of patient information. (CLO 4)
3. Elicits patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and Assessment of care. (CLO 6)
4. Demonstrates respect and sensitivity for diverse patients and patient preferences, values, and needs in providing compassionate care, recognizing own values and beliefs. (CLO 6)
5. Recognizes limits and boundaries of therapeutic patient-centered, nursing care and scope of practice. (CLO 6)
6. Demonstrates knowledge of basic scientific principles and nursing concepts when applying nursing intervention and standards of care to patients across the lifespan. (CLO 4)
Student’s Name:_______________________________________________ Date:__________________________
Patient Age:__________________ Sex:______________________
Patient’s Medical Diagnosis:_____________________________________________________________________
Subjective Data Objective Data
Include all data that the patient provides you (pain level/location, patient descriptions, etc.)
Include all data that you collected or observed (physical assessment, vital signs, urinary output, laboratory values, patient behaviors, etc.)
Based on your subjective/objective assessment data, write your NANDA Nursing Diagnosis on the line below (https://nurseslabs.com/category/nursing-care-plans/nursing-diagnosis/):
____________________________________________________________________________________________________________________
Complete table below:
SMART Goal Nursing Interventions Rationale Assessment
Must include all components of SMART (specific, measurable, achievable, relevant, timely).
Example: Patient will maintain an SpO2 level above 90% on room air by 9/21/19 at 2300.
List three (3) interventions that would help the patient to achieve this goal.
Example: Nurse will encourage ambulation three times daily. Provide reasons as to how each of these three (3) interventions will help the patient to achieve this goal (include citations from reputable source).
Example: Ambulation helps to promote airway clearance and prevent atelectasis. State whether the goal was met, not met, or partially met with rationale.
Example: Goal not met as evidenced by patient requiring 2L of oxygen to sustain an SpO2 level above 90% at 2300 on 9/21/19.
1.
1.
2.
3. 1.
2.
3. 1.
References
Western Dakota Tech
Registered Nursing Program
NURS 260 Medical-Surgical Nursing Across the Lifespan
Concept Map/Care Plan Rubric
Criteria/Points 2.5 1.25 0
Documentation of Data Includes medical diagnosis with pathophysiology, medications, diagnostics, treatments, and objective/subjective assessment. Does not include 1-4 components. Missing 5 or more components.
Relationships Shown Pertinent relationships shown between parts of the concept map. Relationships are shown but confusing or not relevant. Relationships are not shown.
Ease of Readability Easy to follow; clear and useful. Confusing to readers; disorganized. Concept map does not make sense; irrelevant to client.
Integration of Client Shows a high level of understanding of the entire client picture. Shows a moderate level of understanding of the entire client picture. Does not show understanding of the entire client picture.
Nursing Diagnosis Nursing diagnosis is a NANDA nursing diagnosis, is written correctly, and contains all components (r/t, AEB). Nursing diagnosis is not a NANDA nursing diagnosis.
OR
Nursing diagnosis is a NANDA nursing diagnosis but is not written correctly or is missing components. Nursing diagnosis is not included.
OR
Patient identifiers used.
SMART Goal SMART goal is patient-centered and contains all components (specific, measurable, achievable, relevant, and timely). SMART goal is not patient-centered and/or is missing 1-4 components. SMART goal is not included.
OR
SMART goal is missing all 5 components.
OR
Patient identifiers used.
Nursing Interventions/ Rationale At least three interventions that support the written goal are listed with appropriate rationale. All interventions are nurse-centered. One-two interventions that supports the written goal are listed with appropriate rationale and/or interventions are not nurse-centered. Nursing interventions and/or rationale is not included.
OR
Interventions do not support the written goal.
OR
Patient identifiers used.
Assessment Assessment states whether the goal was met, not met, or partially met and rationale was provided. Assessment states whether the goal was met, not met, or partially met but is missing rationale.
OR
Rationale is given but Assessment does not state whether the goal was met, not met, or partially met.
OR
Assessment does not address the specific written goal. Assessment is not included.
OR
Patient identifiers used.
Connection Concept map and care plan correspond with each other. Concept map and care plan are distantly related. Concept map and care plan are disconnected.
References References listed in APA format for all cited material. References not listed in APA format. References not listed.
