Guidelines for Writing Care Plans in All Nursing Courses

Guidelines for Writing Care Plans in all Nursing Courses

SELECTION OF CLIENT FOR CARE PLAN

1. When you are in the clinical setting, get the okay from your Clinical Instructor that a client you select for to write your Care Plan on is an appropriate client to meet objectives of the course. Do this before leaving the clinical area on the day you care for that client.

SUBMISSION DUE DATES 1. Check the course syllabus for the due dates of the care plans. Late submissions will receive a zero.

PRESENTATION 1. Proof read your Care Plan carefully.

 Typos and incorrect English/spelling reduce the grade. If hand written, it must be neat and legible.  Write in the third person, and in scientific, not casual, style.  Use complete sentences for every part except the data lists.

2. Use the Publication Manual of the American Psychological Association (APA) to write your citations.

 Sources must be cited throughout the plan, using correct in-text citation according to APA format. You must include the reference page at the end of the plan, on a vertically oriented page.  An APA style cover page will be included with running head. Page numbers must appear on every page.  Quotation marks must be used when appropriate, always citing the page number. When restating an author's ideas using some of the same phrases the author used, also cite the page number.

3. Submit 1 copy of your plan, but also keep a copy for yourself.

NOTE: WRITE THE CARE PLAN ONE DIAGNOSIS AT A TIME - FROM ASSESSMENT THROUGH EVALUATION. It is better to have one priority diagnosis worked out in detail, than to have several diagnoses that are irrelevant and sketchy.

ASSESSMENT DATA PATTERNS

1. Gather all data according to the form provided. 2. Include all medications given during your shift and in the past 24 hours, even if you didn’t give the medication. Be sure to cite your sources for drug information. 3. In the Subjective Data list include relevant : a. client complaints b. description of the client's support system c. behavioral and nonverbal messages d. client awareness of her/his own:  abilities / disabilities  disease process  prognosis  health care needs  available resources 4. In the Objective Data list include relevant: a. physical assessments including vital signs b. observations of the support system in action c. judgment of the client's readiness for learning, her learning potential, and locus of control d. chart information including lab and test results

NURSING DIAGNOSES

1. When writing a plan that includes several diagnoses, write the diagnosis in order of priority with the highest priority first. 2. A plan must start with the major issues for that client. For example, if the client is in acute distress over one problem, a plan covering only other minor problems would show lack of sensitivity on your part, as well as a lack of critical thinking. 3. Select only diagnoses that are amenable to resolution by actions YOU can take. 4. Write out the three parts of the Nursing Diagnosis ( R.E.D. ): R. The human Response of the client [wellness response / problem ( anxiety)] E. Etiology or related events / factors, designated as R/T D. Data that is evidence of the diagnosis. You have already listed this information under Assessment Data Patterns, so say "as evidenced by ___".

Note: Most human responses are related to several factors. List them all. For example : anxiety related to a. new environment, b. separation from usual support system, c. big exam in two days CLIENT GOALS 1. Number each goal stating the client Goal, the Tool to measure goal achievement, and the Time to evaluate [GTT]: 2. The goal must be stated in terms of client achievement. ( for example : "The client will report a reduction in feelings of anxiety") 3. Each goal must be measurable. You must indicate how you will measure if the goal has been achieved. (for example: "as measured by the client assessing her/his anxiety as less than baseline on a 10 Point Anxiety Scale. It is now 7 on the 10- point scale.") 4. Each goal must state a target date and hour for evaluation. (The Anxiety Scale will be re administered in 24 hours: date, hour.) 5. Write at least one "short term goal" for every Nursing Diagnosis. This will demonstrate your ability to actually help a client achieve a goal. To get credit for the Evaluation section of your Care Plan set a time when you will be there to evaluate goal achievement. ( for example :" by noon today") 6. Some goals that are important for your client are "long term goals". You may write a "long term goal", if appropriate. Your instructors understand that this kind of goal will have a time frame for evaluation that goes past the due date for the Care Plan. See the section on Evaluation on how to word the Evaluation of any "long term goal".

NURSING INTERVENTIONS WITH SCIENTIFIC RATIONALE 1. Immediately following each goal that you write, list specific nursing actions you used to work toward that goal. 2. Nursing actions must be specific, not global, appropriate, and without important omissions. In most cases several (average of 4-5) interventions are needed to achieve any one goal. 3. If your idea to use a nursing action comes from a Care Plan book or other source, cite the source. 4. After each nursing action give the scientific rationale for selecting the action. Cite your source for this rationale. Sources might include a book, lecture, discussion with a health professional or media source. 5. Rationales must be logical and relevant, with a scientific basis. 6. Rationales must be direct quotes, with quotation marks, and with page numbers in the citation.

EVALUATION OF THE PLAN 1. State when you evaluated the goal. This should be the same time you designated in the Goal Statement earlier. (for example: "At noon 8/14/08") 2. Use the measures you designated for goal achievement to state your client's degree of success. (for example: "the client evaluated her anxiety as 4 on a 10- point scale.") 3. Draw conclusions on the interventions used related to the outcome. (for example : "Helping the client to talk about her feelings reduced her anxiety .") 4. Consider changes or additions to the interventions that might improve goal achievement. (For example: "Studying with the client before the next examination should reduce her anxiety even more.") 5. For the "long term goal" you state: "Evaluation of this goal is set for (state the date & time, if possible, or “homegoing”, etc). The client has made (no)(some) (significant) progress toward this goal: (describe any movement toward the goal) GRADING CRITERIA FOR COMPREHENSIVE CARE PLANS

For the Care Plan, the scoring for each of the following elements will be:

15% Quality of data collection, including chart data, medications, psychosocial and physical assessment data. Ability to coalesce the data into objective/subjective differentiations. 10% Quality and relevance of diagnostic statement and evidence. 10% Quality of 3-part goal statements 15% Nursing interventions effective, sufficient quantity, customized to client, and appropriate to goal. 15% Rationale for each intervention is scientific/ logical. Resources cited. 15% Clarity of goal evaluation statement and conclusions 5% Quality of plan revision 15% Presented according to instructions; college level scientific language; citations & works cited appropriate and in APA format. Spelling, typos, grammar—no errors.