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care plan

Last updated: Fall 2020

Care Plan Tips and Examples

*Follow exactly what is on the Care Plan Grading Rubric. Section by section, line by line.

Patient Introduction

o Remember to avoid identifiers to maintain patient confidentiality: No initials, no

birthdate, decade for age, do not give name of facility or hospital. Stage age in

designated range as listed on the rubric.

o Write in paragraph narrative format, following APA format, and complete sentences.

o Include every section in the rubric.

Patient Introduction (Specific Example)

Patient is (give age group 66-74, 75-85, >85 years) Caucasian female. Patient was

admitted to the skilled nursing facility on 9/21/12 after suffering an acute CVA the day after she

had surgery for a hip fracture to her right femoral neck which was required due to a fall at

home. Patient suffers from mild expressive aphasia as a result of the CVA. Her memory of the

events surrounding the fall are not clear. She states that she was not with anyone at the time of

the fall and she does not remember if she blacked out or lost consciousness. She states that

someone found her in her apartment and she was taken to Hospital where she said she had a

“rod” put in her hip.

Patient has a past surgical history of hemiarthroplasty for her right femoral neck

fracture, back surgery, lumpectomy for breast cancer, and tonsillectomy. She also has a past

history of HTN, DM, high cholesterol and glaucoma. Patient’s father and mother died of

natural causes. Some diabetes in the family.

Patient has lived in the DC area all her life. She attended college and graduate school and

states that she got a degree in food service management and she “fully enjoyed” that. She was

never married and does not have any children. However, she states that she has many friends

who she sees and visits with often. She enjoys visiting with all her friends and spending time

with people.

She expects to be able to return home to her apartment at an assisted living facility within

the next week. She says that she has a lot of friends who will help her. She also has a cousin who

is a surgeon who has been helping with everything.

Patient does not have any known allergies.

Code: Attempt CPR

Last updated: Fall 2020

Assessment and Interpretation

*Physical Assessment: Use your textbook! Problems identified are stated as NANDA Diagnosis and

follow the assessment. Include all body systems.

Example:

Assessment: 10/26/2025 and 11/2/2025 Problems:

G-U: 10/26/25

Patient denies problems with urination. Patient states that she urinates 4-5

times a day and states that her urine appears “clear with nothing

abnormal”. When asked about fluid intake, patient states that she should

“probably drink more water” and she then proceeded to drink some of her

water at her bedside.

When the patient showed me the scar on her right hip from her hip surgery,

I noticed she also was wearing depends. I should have asked her if she had

any problems with incontinence after noticing the depends.

-Risk for deficient fluid volume

r/t decreased intake AEB

patient’s report that she

should “probably drink more

water” (Doenges, Moorhouse,

& Murr, 2010, p. 379-380).

DocuCare Documentation: Ensure that you patient documentation is complete, accurate, and submitted
for instructor review. Document your assessment and any interventions conducted.

*Individualize each lab result to the specific patient.

For example: Labs, why is it normal or why would it be high/low according to the patient’s

history and current condition. The patient has low hemoglobin and hematocrit because they are

anemic. This is the same for meds. Ask yourself “Why is this patient taking this medication?”

The patient is taking Norvasc because they have a history of high blood pressure.

*You may make charts for labs and meds. For Labs, split, normal range, patient’s result, and

significance. For medications, split medication, dose/route/frequency, drug class and Mechanism of

Action (MOA,) indication for YOUR patient. Don’t forget to cite your lab and medication chart (ie: where

did you find the information for normal values, drug class, MOA, and significance).

Examples

Lab Normal Value* Patient’s Result Significance*

RBC 3.90 – 5.40mil/uL 3.46 Low

Expected finding based on patient’s

diagnosis of anemia

*Citation for lab table

Last updated: Fall 2020

Medication

Generic and Trade

Name

Drug

Classification

and MOA*

Patients

Dose/Route/Frequency

Indication

(Purpose specific to this
patient)*

Calcium Carbonate

and Cholecalciferol

(Caltrate Plus D)

Calcium

supplement and

vitamin D

Hormone.
MOA: Essential
component and
participant in
physiologic
systems and
reactions.

Calcium Carbonate 600mg

Cholecalciferol 400mg

1 tab PO daily

Calcium for low levels of calcium

in the blood and Vitamin D to

prevent muscle pain with statins.

*Citation for Medication table

Other Diagnostic

Tests

Results Significance*

Chest X-ray

(12/25/2025)

No evidence of active cardiopulmonary disease.

Reveals peripheral lung fields are clear of lobar

infiltrates and effusions. Cardiac silhouette and

pulmonary vascularity are normal.

Expected finding based on

patients history of no lung or

cardiac problems.

*Citation for diagnostic table

Last updated: Fall 2020

Pathophysiology Flowchart

*You need 4 pathophysiologic factors affecting this patient’s condition and needs to be described. Also

illustrate interrelationships among the factors. Will need to use a flowchart.

*It is best to create your flowchart in another document and insert a screenshot/image of your

flowchart versus creating it within the body of your care plan paper. If you create it in your care plan

paper it will easily become distorted as your instructor gives feedback on your paper.

Example:

Last updated: Fall 2020

-Morbidity and mortality statistics: risk factors, population groups affected, resulting morbidity and

mortality. You will need to search journal articles and/or the CDC to find this data.

Diagnosis

When identifying 2 physical and 2 psychosocial diagnoses, use nursing diagnosis. Problem (diagnosis)

related to etiology (contributing factor) as evidence by symptom (signs and symptoms). R/T, AEB

Label diagnoses according to priority

Plan

A plan is written for one physical and one psychosocial diagnosis -Goals with characteristics

3 short term goals, and 1 long term goals that are patient centered, measurable behavior, specific in

content and time, attainable, and address the diagnosis. The goals must be MEASUREABLE!

Example:

EXPECTED OUTCOME NURSING INTERVENTIONS EVALUATION/

CHANGE IN PLAN

SHORT TERM GOAL(S)

By the end of the shift,
the patient will
smoothly transfer from
sitting in the wheelchair
to standing.

By the end of the shift,
the patient will walk 50
feet with a walker.

By the end of the shift,
patient will demonstrate
active range of motion
(ROM), isotonic, and
isokinetic exercises to
perform while in the bed
or wheelchair to
strengthen muscles and
increase joint
ROM.

The nurse will:

Consult with physical and occupational therapists
to “develop individual exercise and mobility
program, and identify appropriate mobility
devices” (Doenges,
Moorhouse, & Murr, 2010, p. 530). Rationale –
physical and occupational therapists are specially
trained to develop and implement appropriate
exercises and goals for patients who have physical
disabilities.

Encourage and assist patient to perform
strengthening exercises of the left arm. Rationale
– patient has decreased strength in her right arm
so this impairs her to push up when trying to get
out of the wheelchair.

Encourage client to practice transferring from
sitting in the wheelchair to standing 1-2 times for
every program she watches on television or 1-2
times every hour.

Demonstrate use of and help patient become
comfortable with use of the walker. Rationale – if
patient has never used a walker before, she needs
to be shown the proper way to ambulate with one.

Goal – By the end of the shift, the
patient will smoothly transfer from
sitting in the wheelchair to standing.

• Goal was partially met.
Patient performed
strengthening exercises of the
left arm and reported that the
left arm felt a little bit
stronger when she used it to
get up from the wheelchair.
Patient was still somewhat
shaky and wobbly when
transferring to a standing
position from the wheelchair.
Patient should continue to
perform strengthening
exercises for the left arm to
further strengthen it to get
out of the wheelchair.

Goal – By the end of the shift, the

patient will walk 50 feet with a walker.

• Goal was exceeded. Patient

was able to quickly master the

use of the walker and was

able to ambulate up and down

Last updated: Fall 2020

the hallway 75 feet. I will

modify the goal by increasing

the distance to 100 feet with

the walker.

Goal- By the end of the shift, patient
will demonstrate active range of
motion (ROM), isotonic, and isokinetic
exercises to perform while in the bed
or wheelchair to strengthen muscles
and increase joint
ROM.

Goal met. Patient demonstrated active
range of motion (ROM), isotonic, and
isokinetic exercises to perform while
in the bed or wheelchair to strengthen
muscles and increase joint
ROM.

LONG TERM GOAL

By discharge, the
patient will ambulate
100 feet without
assistance of the
walker and without
assistance of another
person and only using a
cane.

Schedule specific times to practice walking down
the hallway with the walker “with adequate rest
periods during the day to reduce fatigue”
(Doenges, Moorhouse, & Murr, 2010, p. 530).
Rationale – time for practice should be scheduled
around physical therapy, meals, and other
activities and patient should be provided
adequate time to rest between practice sessions
and after physical therapy to prevent
overworking the muscles and to prevent
exhaustion and fatigue.

Goal- By discharge, the patient will
ambulate 100 feet without assistance
of the walker or another person; and
only using a cane.

• Goal met. Patient was able to
walk > 100 feet using the cane
only.

(Doenges, Moorhouse, & Murr, 2010)

Intervention

Any direct care nurse performs on behalf of patient.

Evaluation of the patient’s status, of patient’s progress toward goal achievement, of the care plan’s

status, suggestions to improve.

Use APA format. You can make an appointment with the Writing Center to correct grammar and proper

APA format.

  • Care Plan Tips and Examples
  • Patient Introduction
  • Assessment and Interpretation
  • Pathophysiology Flowchart
  • Diagnosis
  • Plan
  • Intervention

Fundamentals of Nursing Care in the Context of Older Adults
Virtual Patient Care Plan Grading Sheet Fall 2021

Poor

Limited

Good Very Good Excellent

Section Description of Points Does not meet
criteria or

section missing

Partially meets
criteria with
major errors

Partially meets
criteria with

marginal errors

Meets
criteria with
minor errors

Meets full
criteria

Patient
introduction

• Full sentences

• Grammatically
correct

• Only
acceptable
abbreviations

Includes, in order:
No initials, please refer to ‘Patient’ as identifier

• Age, gender, race: (State age as: <65 years,
65-74, 75-84, 85-95, >95 years)

• Reason for admission

• History of present illness

• Past medical/surgical history summary (If
unknown, state what questions you would
ask)

• Allergies

• Code status (If unknown, state what you
would expect based on the client’s
condition)

0 2 3 4 6

Assessment and
interpretation

• Focused assessment complete and accurate
(pertinent to the objectives of case)

• Problems identified are in keeping with the
data recorded and are stated as a NANDA
Diagnosis

• Section identifying areas you would like to
assess but were unable to do so.

0 4 6 8 10

DocuCare
Documentation

• DocuCare assessment submission is
complete, on time, and accurate.

• Assessment and interventions documented
correlates with care provided.

0 0.5 1 1.5 2

Fundamentals of Nursing Care in the Context of Older Adults
Virtual Patient Care Plan Grading Sheet Fall 2021

Poor

Limited

Good Very Good Excellent

Does not meet
criteria or

section missing

Partially meets
criteria with
major errors

Partially meets
criteria with

marginal errors

Meets
criteria with
minor errors

Meets full
criteria

Diagnostic data • Lab and radiology data results are correctly
interpreted in light of the patient’s history
and current condition.

• Normal and abnormal interpretation of lab
and radiology data is interpreted and
discussed for significance to patient status
and disease pathology.

• If lab/diagnostic data is unavailable, discuss
what would be warranted or recommended
with appropriate cited rationale

0 2 4 6 8

Medications • Medication list correctly identifies the
mechanism for action, drug classification,
patient’s dosage, and purpose of each
medication specific to this particular patient

• If your patient is not ordered any
medications: Suggest at least 4 medications
that you might request the provider order
for this patient in light of their condition
and list the MOA, drug classification,
suggested dose, and potential purpose/
your rationale for recommending specific to
this patient

0 2 4 6 8

Fundamentals of Nursing Care in the Context of Older Adults
Virtual Patient Care Plan Grading Sheet Fall 2021

Poor

Limited

Good Very Good Excellent

Does not meet
criteria or

section missing

Partially meets
criteria with
major errors

Partially meets
criteria with

marginal errors

Meets
criteria with
minor errors

Meets full
criteria

Pathophysiology
flowchart

Pathophysiology flowchart –
Pathophysiology of the most relevant disease
process must be described (not defined)

• At least 4 pathophysiologic factors affecting this
patient’s condition needs to be described

• Illustrates interrelationships among the factors
(i.e., cause, effect, increases, decreases,
predisposes, protects, etc.)

0 3 4 6 7

Morbidity and
mortality

• Full
sentences

• Grammati
cally
correct

• Only
acceptabl
e
abbreviati
ons

Morbidity and mortality statistics are given for the
pathophysiological disease process discussed in
flowchart incidence and/or prevalence

• risk factors

• population groups affected

• resulting morbidity and mortality

0 1 2 3 4

Diagnosis Two physical and 2 psychosocial diagnoses are
identified

0 2 3 4 5

Diagnoses are in keeping with assessment data
recorded within paper

0 2 3 4 5

Diagnoses are high priority and amenable to nursing
intervention

0 2 3 4 5

Diagnoses use NANDA labels and are correctly
expressed (i.e., include etiology and/or defining
characteristics as appropriate – PES as discussed in
lecture problem, etiology and sign/symptoms)

0 2 3 4 5

Fundamentals of Nursing Care in the Context of Older Adults
Virtual Patient Care Plan Grading Sheet Fall 2021

Poor

Limited

Good Very Good Excellent

Does not meet
criteria or

section missing

Partially meets
criteria with
major errors

Partially meets
criteria with

marginal errors

Meets
criteria with
minor errors

Meets full
criteria

Plan A plan is written for one physical and one
psychosocial diagnosis

0 2 3 4 5

Outcome or goals Outcome statements

• address the diagnosis

• are realistic and patient specific

• are measurable, observable and stated with
appropriate time frame

• Must have at least 1 long term goal and 3 short
goals for each problem identified

0 2 3 4 5

Implementation
(Intervention)

Interventions are

• appropriate to address the diagnosis

• safe, patient specific and appropriate

• some are original or innovative (need to be
stated with own rationale)

• Rationales are given for each intervention and
are appropriately cited via APA format

0 4 6 8 10

Interventions take into account this patient’s unique
strengths, resources, and/or preferences

0 2 3 4 5

Evaluation A statement as to whether goals were met or not
met is made for each outcome; if met quantify or
qualify the degree to which the outcome was
achieved.

0 2 3 4 5

Fundamentals of Nursing Care in the Context of Older Adults
Virtual Patient Care Plan Grading Sheet Fall 2021

Poor

Limited

Good Very Good Excellent

Does not meet
criteria or

section missing

Partially meets
criteria with
major errors

Partially meets
criteria with

marginal errors

Meets
criteria with
minor errors

Meets full
criteria

APA Format

• Spelling

• Grammar

• Punctuation
Clarity of writing
are all a part of
APA style

Must have at least three references- (unless a
seminal paper, none older than 5 years). References
must be properly cited using APA format.
https://owl.english.purdue.edu/owl/resource/560/0
1/

0 2 3 4 5

TOTAL Points 100