Nursing Care Plan Template
In the care plan template provided, identify 4-6 actual or potential physiological patient problems.
Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).
Identify the optimal outcome that your patient should achieve before they are discharged.
Do not include nursing interventions in the template.
Problems may be:
• actual health problems: a health problem that is currently present or occurring and needs intervention to either end or reverses its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.
Examples: Dehydration due to ……..
Wound infection related to ……
Acute pain related to ….
Impaired skin integrity due to ….
Inadequate tissue perfusion related to……..
• potential health problems: a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
The patient is ‘at risk of’ falls due to …
The patient is ‘at risk of’ developing a DVT due to….
The patient is at risk of infection due to………
For potential health problems, please consider that you are identifying the risk based on evaluation of the data you have been given in the case study. As such, the assessment data will be what puts the patient at risk rather than the assessment data the patient would have if they had this problem as an actual problem. For example, the assessment data for an actual DVT will be redness, swelling, pain, heat while the assessment data for a potential DVT might be reduced mobility, low BP, activation of inflammatory response.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
Actual or potential problem
Actual problem: the patient is dehydrated related to decreased fluid intake
The patient is ‘at risk of’ infection due to compromised host defences
Note: you can use commonly used abbreviations or symbols, e.g. BP for blood pressure.
No marks are allocated to the template, however it is required to be submitted in order to receive a pass grade for this assessment.
Nursing Care Plan Report – 2000 words
From your nursing care plan template select 2 (two) physiological problems. These may be actual problems, potential problems or one of each. Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these and they will not be marked.
For each of your chosen problems:
As this is a formal academic report you should include
– an introduction: identify which patient case study you are using and the purpose/direction of your report e.g. “… This report will discuss compartment syndrome and surgical wound breakdown as two actual problems experienced by Mr. Smith. The pathophysiology of these conditions will be outlined along with nursing interventions required to treat these problems…”
– a conclusion: 1 or 2 sentences only which sum up your work. The conclusion should not include references as it is a summary of your ideas only.
– at a third year BN level, for a 2000 word report you should have at least 20 high quality sources of evidence
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