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Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
Proposed common guidelines in the preparation and evaluation of student nursing care plan (a  proposal to the nursing education teaching  learning groups)
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Proposed common guidelines in the preparation and evaluation of student nursing care plan (a proposal to the nursing education teaching learning groups)

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  • 1. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlanA PROPOSAL TO: Nursing Education Teaching-Learning Groups By. Katherine P. Barnachea, RN March 2012
  • 2. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans TABLE OF CONTENTSContents Page Introduction 2 Purpose 3 Common Guidelines in the Preparation and 3 Evaluation of Student Nursing Care Plan A. Common Guidelines in the Preparation of 4 Student Nursing Care Plan (Student Guide) B. Common Guidelines in the Evaluation of 9 Student Nursing Care Plan (Faculty Guide) Suggested Student Nursing Care Plan Format 13 Summary 14 Reference 14 Appendix 15 A. Suggested Student Nursing Care Plan Working Guide B. Suggested Nursing Care Plan Output Format 1
  • 3. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansIntroduction Student oriented nursing care plan as a writing assignment of thestudent nurses in their experiential practice, has been used by the nurseeducators as a teaching device to facilitate the student’s understanding inpatient’s situation and on solving identified nursing problems. This writingassignment contains reflection on the application of nursing process ascritical thinking method to solve problems in the nursing practice. With the long years that this traditional care plans have been used bythe student nurses there are several problems found in evaluating these careplans, as used by the students. The results presented in the study about“Critical Analysis of Student Nursing Care Plans in the Nursing Schools ofDagupan City” clearly detailed the deficiencies on the level of accomplishmentof the analyzed student nursing care plan entries along the literaturerequirements of nursing process. With this, the attempt to align the soughtdeficiencies was summed up to creating proposed common guidelines on thepreparation and evaluation on writing nursing care plan of student nurses.This guideline will be used by both the students and their clinical instructors.The proposal of these common guidelines will serve as an anchor to establishthe critical thinking and decision making skills of student nurses as theylearn the application of nursing process into practice. In the same way, theclinical instructors can easily evaluate their progress and therefore candetermine their performance in the nursing practice. Through theseguidelines, students will learn the very objective of writing a good nursing careplans, and its future implications on their identity as professionals. 2
  • 4. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansPurpose 1. The common guideline on preparation of nursing care plan will serve as the foundation instructions for the student nurses on how they will apply nursing process in their nursing care plan writing. The guideline will lead them to proper assessment, conclusion and statement of diagnosis, creating a reasonable plan of care, implementation of plan into practice and proper evaluation of their nursing care. As the students continue to enhance this practice, the development of their professional identity as a nurse, distinct from other health professions will be developed. 2. The common guidelines on the evaluation of student nursing care plan will serve as a grading tool for the nursing faculty to determine the progress of the students in writing their nursing care plans. Common Guidelines on the Preparation and Evaluation of Student Nursing Care Plan The proposed common guidelines on the preparation and evaluation ofstudent nursing care plans were anchored from Kozier, et al., (2004)literatures of nursing process. The guidelines follow the steps of nursingprocess: assessment, diagnosis, planning, implementation and evaluation.Each area of nursing process contains guide indicator that was modified tospecifically lead the students in the preparation of the entries to be written onthe nursing care plan. In the same way grading tool to determine if theguidelines were met was drafted as an evaluation instrument to be used bythe nursing faculty. 3
  • 5. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans A. Common Guidelines on the Preparation of Student Nursing Care Plan (Student’s Guide) The following guidelines will help the students on the preparation oftheir nursing care plans.ASSESSMENT Assessment is the first phase of Nursing Process. In this phase,collection, validation and organization of data are done. Significant data thatwill lead to the realization of an actual or potential problem is gathered, andwill then be a basis of establishing a nursing care plan. Guidelines to considerassessment writing in student nursing care plans are as follows: 1. Collection and documentation of subjective and objective data using appropriate terminology. 2. Gathering of the primary source of data from the Client: Physical, Psychological, social-cultural, developmental, spiritual and environmental conditions. 3. Gathering of the secondary source of data from the client’s support people, cephalo-caudal assessment and observation of the nurse. 4. Gathering of Client’s Records (medical history, therapeutics and laboratory results) as a supporting data to the assessment. 5. Review of related literature (e.g. Reference text regarding specific health problems, professional journals, information about the medical diagnosis, related readings etc.) as a supporting data to the Assessment entries. 6. Organization of data according to the Policies and Standards of the Bachelor of Science and Nursing Program Nursing Care Management Subjects. 7. Clarification of vague or ambiguous statement of the client. 4
  • 6. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans 8. Double checking of Data with extremely abnormal results. 9. Use of reference (textbooks, journals, research reports) to explain the patient’s situation.DIAGNOSIS Diagnosis contains a concluding statement for an actual or potentialproblem. To have an accurate conclusion of a nursing diagnosis, guidelineswere presented as follows: 1. Comparison of significant cues against the standards, such as growth and development patterns, normal vital signs and laboratory values. 2. Generation of tentative hypotheses after determining the relatedness of facts and determining whether any pattern are present or whether the data is significant. 3. Identification of the gaps and inconsistencies in the data to ensure that data are complete and correct. 4. Selection of the nursing diagnoses/collaborative problems that will reflect the accurate interpretation of the subjective and objective data analyzed. 5. Listing of appropriate Subjective and objective data as supporting data for the nursing diagnosis. 6. Proper usage of NANDA terminology as nursing diagnosis. 3 part statements for an actual problem- Problem, Etiology, Signs/ Symptoms (PES format). Risk nursing diagnosis use 2 part statements and syndrome diagnoses use 1 part statements. 7. Writing of accurate, concise, descriptive and specific Diagnostic statements. 5
  • 7. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansPLANNING Planning includes the goals of care and guide selections on the specificnursing interventions to solve the nursing problems defined in the NursingDiagnosis. Guidelines in creating a plan of care were as follows: 1. Prioritizing plan considering the client’s health values and beliefs, resources available to the nurse and client, urgency of health problem and medical treatment plan. 2. Describing client’s goals / desired outcome in terms of client responses and what the nurse hopes to achieve by implementing the nursing interventions. 3. Deriving of goals from the client’s nursing diagnosis primarily from the first clause (problem). 4. Consideration that goals and outcomes are realistic for the client’s capabilities, limitations and designated time span if it is indicated. 5. Ensuring that goals and desired outcome were compatible with the therapies of other professionals. 6. Consideration that each goal is derived from only one nursing diagnosis. 7. Used of observable, measurable terms on the desired outcomes. 8. Inclusion of the subject, verb, conditions or modifiers and criterion of desired performance in Goal / Desired Outcome Statement. 9. Consideration of safe and appropriate intervention for the individual’s age, health and condition. 10. Clearly stating achievable intervention with the resources available. 11. Consideration that interventions were congruent with the client’s values, beliefs and culture. 12. Linking specific interventions to specific outcomes. 6
  • 8. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans 13. Realistic and appropriate statement of the patients current status. 14. Comprehensive and scientific reasoning and identification why the intervention was selected as rationale for each intervention. 15. Discussion of possible side effects or complication on the specific interventions.IMPLEMENTATION Implementation is the safe carrying out of the planned intervention, anurse completes this phase by documentation of the intervention done andthe patient’s response on the intervention implemented. Guidelines to safelycarry out this process are presented by the following: 1. Reassessing the client before implementing an intervention, making sure if the intervention is still needed. 2. Determining the need for assistance and awareness of the nursing interventions that student nurse are capable and allowed to do in accordance with the affiliating institutions policy. 3. Implementation of safe care. 4. Encouraging active participation of the client in implementing the nursing interventionEVALUATION Evaluation is done to determine the progress of the patient in relation tothe goals and stated outcome criteria in the plan of care and to determinewhether the problem was resolved or not. 7
  • 9. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans1. Collection of data using the clearly stated, precise and measurable outcome as a guide, so that conclusions can be drawn about whether goals have been met.2. Comparison of the gathered data as an evaluation of client’s response was compared with the outcome. Stated goal was met if the client’s response is the same with the desired outcome. Goal was partially met if the desired outcome was only partially attained. Goal was not met if any of the desired outcomes wasn’t met.3. Determining whether the nursing activities have relation to the outcome.4. Explaining why goals were met or unmet. Including specific data on the effectiveness of interventions. 8
  • 10. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans A. CommonGuidelines on the Evaluation of Student Nursing Care Plans (Faculty Guide) This guideline will serve as an evaluative tool to determine the application ofnursing process in the written student nursing care plans. The nurse educator willassess the extent of accomplishment of the student nursing care plan entries inaccordance to the specified guidelines in each areas of nursing process. The facultyevaluator will put check marks on the spaces available to determine if each indicatorguideline were: Fully Accomplished (F.A.) = 4points, Moderately Accomplished (M.A.)= 3points, Least Accomplished (L.A.) =2 points, and Not Accomplished (N.A.) = 1point. I. ASSESSMENT- minimum acceptable score is 25 ASSESSMENT F.A. M.A. L.A. N.A (4) (3) (2) (1) 1. Collection and documentation of subjective and objective data using appropriate terminology. 2. Gathering of the primary source of data from the Client: Physical, Psychological, social-cultural, developmental, spiritual and environmental conditions. 3. Gathering of the secondary source of data from the client’s support people, cephalo-caudal assessment and observation of the nurse. 4. Gathering of Client’s Records (medical history, therapeutics and laboratory results) as a supporting data to the assessment. 5. Review of related literature (e.g. Reference text regarding specific health problems, professional journals, information about the medical diagnosis, related readings etc.) as a supporting data to the Assessment entries. 6. Organization of data according to the Policies and Standards of the Bachelor of Science and Nursing Program Nursing Care Management Subjects. 7. Clarification of vague or ambiguous statement of the client 8. Double checking of Data with extremely abnormal results 9. Use of reference (textbooks, journals, research reports) to explain the patient’s situation. SCORE = 9
  • 11. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansII. DIAGNOSIS- minimum acceptable score is 20 DIAGNOSIS F.A. M.A. L.A. N.A (4) (3) (2) (1)1. Comparison of significant cues against the standards, such as growth and development patterns, normal vital signs and laboratory values.2. Generation of tentative hypotheses after determining the relatedness of facts and determining whether any pattern are present or whether the data is significant.3. Identification of the gaps and inconsistencies in the data to ensure that data are complete and correct.4. Selection of the nursing diagnoses or collaborative problems that will reflect the accurate interpretation of the subjective and objective data analyzed.5. Listing of appropriate Subjective and objective data as supporting data for the nursing diagnosis.6. Proper usage of NANDA terminology as nursing diagnosis. 3 part statements for an actual problem- Problem, Etiology, Signs/ Symptoms (PES format). Risk nursing diagnosis use 2 part statements and syndrome diagnoses use 1 part statements.7. Writing of accurate, concise, descriptive and specific Diagnostic statements. SCORE = 10
  • 12. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansIII. PLANNING- minimum acceptable score is 42 PLANNING F.A. M.A. L.A. N.A (4) (3) (2) (1)1. Prioritizing plan considering the client’s health values and beliefs, resources available to the nurse and client, urgency of health problem and medical treatment plan.2. Describing client’s goals / desired outcome in terms of client responses and what the nurse hopes to achieve by implementing the nursing interventions.3. Deriving of goals from the client’s nursing diagnosis primarily from the first clause (problem).4. Consideration that goals and outcomes are realistic for the client’s capabilities, limitations and designated time span if it is indicated.5. Ensuring that goals and desired outcome were compatible with the therapies of other professionals.6. Consideration that each goal is derived from only one nursing diagnosis.7. Used of observable, measurable terms on the desired outcomes.8. Inclusion of the subject, verb, conditions or modifiers and criterion of desired performance in Goal / Desired Outcome Statement.9. Consideration of safe and appropriate intervention for the individual’s age, health and condition.10.Clearly stating achievable intervention with the resources available.11.Consideration that interventions were congruent with the client’s values, beliefs and culture.12.Linking specific interventions to specific outcomes.13.Realistic and appropriate statement of the patients current status.14.Comprehensive and scientific reasoning and identification why the intervention was selected as rationale for each intervention.15.Discussion of possible side effects or complication on the specific interventions. SCORE = 11
  • 13. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans IV. IMPLEMENTATION- minimum acceptable score is 11 IMPLEMENTATION F.A. M.A. L.A. N.A (4) (3) (2) (1) 1. Reassessing the client before implementing an intervention, making sure if the intervention is still needed. 2. Determining the need for assistance and awareness of the nursing interventions that student nurse are capable and allowed to do in accordance with the affiliating institutions policy. 3. Implementation of safe care. 4. Encouraging active participation of the client in implementing the nursing intervention. SCORE = V. EVALUATION- minimum acceptable score is 11 EVALUATION F.A. M.A. L.A. N.A (4) (3) (2) (1) 1. Collection of data using the clearly stated, precise and measurable outcome as a guide, so that conclusions can be drawn about whether goals have been met. 2. Comparison of the gathered data as an evaluation of client’s response was compared with the outcome. Stated goal was met if the client’s response is the same with the desired outcome. Goal was partially met if the desired outcome was only partially attained. Goal was not met if any of the desired outcomes wasn’t met. 3. Determining whether the nursing activities have relation to the outcome. 4. Explaining why goals were met or unmet. Including specific data on effectiveness of interventions. SCORE =*Resubmission of written nursing care plans is recommended if thestudent NCP did not met the minimum acceptable score in any of theareas of nursing process. 12
  • 14. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansSuggested Nursing Care Plan Format Traditional student nursing care plan format involves six columnswhich include: assessment, diagnosis, planning, intervention, rationale andevaluation. This format has been used for long years in the nursing educationsince nursing process was defined as the critical thinking method in thenursing profession. From the past years, student resort to putting necessaryentries needed in the component format of traditional care plans, withoutrealizing if the entries are applicable or not.Several problems foundspecificallyon the detailed implementation of students in the planned care. In this regard, a working guide format was suggested (see Appendix A)anchored from the proposed preparation on student nursing care plans wasmade to be used by the students in leading them to proper analysis andnecessary writing of entries on their care plans. After following eachstepswritten summary of care will be transferred on the suggested format tohave a more detailed documentation in the application of nursing process.This suggested format has followed the specific steps of nursing process:assessment, diagnosis, planning, implementation and evaluation. This formatwas anchored to the suggested guidelines on the preparation and evaluationof student nursing care plan. The assessment column contains the subjective and objective data foran actual or potential problem. Supporting data that contains explanation asto how the proposed guidelines on the preparation of nursing care plan in thearea of assessment will be discussed in separate page of paper. The diagnosiscolumn contains the conclusion of the problem using NANDA (North AmericanNursing Diagnosis Association) approved nursing diagnosis. Planningincludes the determination of desired outcome, and planned specificinterventions. Rationale of interventions will be discussed on separate page ofpaper. The implementation column includes the detailed documentation on 13
  • 15. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Planshow the student nurses were able to execute the plan care. Lastly, theevaluation column will detail the progress of planned care. See the suggestedformat in Appendix B.Summary The common guideline on the preparation and evaluation of studentnursing care plan was proposed to settle the different problems arising on thepreparation and evaluation of nursing care plans done by the students. A tryout on this guideline assumes to benefit both the student and faculty.Anchored from the proposed guidelines is the suggested nursing care planformat that was modified from traditional nursing care plan format was madeto relay written information on the application of nursing process in thestudent nursing care plan writing (see Appendix).Reference:Kozier, B., Erb, G., Berman, A., Fundamentals of Nursing Practice,Synder, S. Concepts, Process and Practice 2004 Seventh Edition, Person Education Inc., New JerseyC.M.O. 14. Series of 2009 Policies and Standards for Bachelor of Science in Nursing (BSN) Program 14
  • 16. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansAPPENDIX -A Suggested Student Nursing Care Plan Working GuideName of Patient: ___________________ Medical Diagnosis: _____________________Age: ________ Room Number/ Hospital Department: _________________________ASSESSMENT-Primary Source of Data (statement from the Client’s complaints)- organized ifthe statement talks about physical, developmental, psychological, spiritual,sociocultural or environmental conditions Physical: ____________________ Developmental: ________________________ Psychological: _________________Spiritual: ____________________________ Sociocultural: ______________ Environmental Conditions: ____________Secondary Source of Data Support People: ______________________ Cephalo-caudal Assessment- documentation of findings should be written clearly on the spaces provided below Integument: _________________________________ Head: _______________________________________ Neck: _______________________________________ Back: _______________________________________ Anterior Trunk: ______________________________________________ Abdomen: ___________________________________________________ Musculoskeletal System: _____________________________________ Neurologic System: ___________________________________________ Genitourinary System: ________________________________________ Other Observations: ___________________________ Vital Signs: RR-_____ T- _______ PR- _______ BP- _________ 15
  • 17. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansClient’s Records: Medical History: * (brief summary)________________________________________________________________________________________________________________________________________________________ Therapeutics: *(must have possible relation to the significant cues)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Laboratory Results:* (pertinent data that may relate to the significant cues)________________________________________________________________________________________________________________________________________________________Review of Related Literature about the Medical Diagnosis________________________________________________________________________________________________________________________________________________________________________________________________________________________________ *(write the reference material used.)Summary of Significant Cues Subjective Data: __________________________ Objective Data: __________________________ 16
  • 18. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansOrganization of Data:Put check marks on the space provided to organize the data gathered fromyour assessments. ___ Care for Mother, Child and Family ___ Care for Mother, Child, Family and Population Group At risk or with Problems ___ Care of Clients with Problems in Oxygenation ___ Care of Clients with Problems in Fluid and Electrolytes Balance ___ Care of Clients with Problems in Metabolism and Endocrine ___ Care of Clients with Problems in Inflammatory and Immunologic Response ___ Care of the Clients with Problems in Perception and Coordination ___ Care of the Clients with Problems in Cellular Aberrations ___ Care of Clients with Problems in Acute Biologic Crisis ___ Emergency and Disaster Nursing ___ Nutrition and Diet Therapy ___ Pharmacology / Therapeutics Thought Provoking Questions: Had you clarified any vague or ambiguous statement of the client? ___YES ___NO Had you double checked data with extremely abnormal results? ___YES ___NOExplain the present patient’s situation briefly: *(write your reference)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 17
  • 19. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansDIAGNOSIS Does the significant cues compared against the standards: o Growth and Development? o Normal Vital Signs? o Normal Laboratory Results? ___YES ___NO Tentative hypothesis of the problem: __________________________ Thought Provoking Questions:Are there any gaps or inconsistencies in the data collected? ___YES ___NODoes the Nursing Diagnosis reflect accurate interpretation of the subjectiveand objective data analyzed?____YES ____NO Final Nursing Diagnosis: Problem: _______________________________ Etiology: _______________________________ As evidenced by Signs and Symptoms: _____________________PLANNING Goals / Desired Outcome:_________________________________________________________________________ Thought Provoking Questions:Does the desired goals primarily address the problem? ___YES ___NOIs the desired goals realistic for the client’s capabilitites? ___YES ____NOIs it compatible with the therapies of other professionals? ___YES ____NOIs your goal derived from only one Nursing Diagnosis? ___YES ___NODid you used obeservable, measurable terms on the desired outcomestatement? ___YES ___NO 18
  • 20. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansDid you included the subject, verb, conditions or modifiers and criterionperformance in the Goal/ desired outcome statement? ___YES ___NO Specific Interventions: Independent Interventions Dependent Interventions Collaborative Interventions1. 1. 1.2. 2. 2.3. 3. 3.4. 4. 4.5. 5. 5. *(number each interventions according to priority) 19
  • 21. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans Thought Provoking QuestionsWere the interventions safe and appropriate for the individual’s age, healthand conditions? ___YES___NOWere the interventions stated clearly achievable with the resources available?___YES ___NOWere the interventions congruent with the client’s values, beliefs and culture?___YES ___NOCite the Rationale of Each Intervention- must contain scientific reasoning anddiscussion of possible side effects or complication of the specific interventions. Independent Dependent Intervention CollaborativeIntervention (Rationale) (Rationale ) Intervention (Rationale )1. 1. 1.2. 2. 2.3. 3. 3.4. 4. 4.5. 5. 5. 20
  • 22. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansIMPLEMENTATION Must Know! Reassess the client before implementing the intervention, making sure if it is still needed. ____Done _____Not done Determine the need for assistance: ____Done ___Not done Implement Safe Care: ____Done _____Not done Encourage active participation of the client in the implementation of interventions: ___Done ___Not done Write the Documentation of Care in Narrative Form- Implementation ofcare must be reflected according to the plans you’ve constructed above. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EVALUATION:Activity: Collection of data using the desired outcome as a guide.Restate the desired outcome: __________________________________________Evaluation Data Collected :____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 21
  • 23. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans Thought Provoking Question: Do the nursing activities/ interventions implemented have relation to the present outcome of patient? _____ YES ___NOState if the goal was met, partially met or not met and explain why:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Good Job!!! You can now summarize your written care plan on the suggestedstudent nursing care plan format. 22
  • 24. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care PlansAPPENDIX –B Suggested Nursing Care Plan Output FormatName of Patient: ____________ Age: ____Medical Diagnosis: _________________Hospital Department: __________________ Room: ___________Date: _______ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Desired THIS COLUMN WILL Contents onSubjective Outcome: BE THE ACTUAL this columnData: NARRATIVE will include DOCUMENTATION discussion on Problem OF THE STUDENTS the progress of _____________ ON THE patient in Etiology IMPLEMENTATION relation to the _____________ OF PLANNED CARE. goals andObjective Data: Signs and Interventions: stated outcome symptoms / criteria. Defining Objectives ______________Name of the Student: ___________________________Clinical Instructor: _____________________________ 23
  • 25. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans 24

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