Nursing Care Plan and Diagnosis

1. Nursing Care Plan and Diagnosis for Chronic Pain
Nursing Care Plan and Diagnosis for Chronic Pain
This nursing care plan is designed for patients with chronic discomfort. According to Nanda,
chronic pain is the condition in which an individual experiences persistent or intermittent pain
that lasts for more than six months. This definition differs from that of acute pain, in which a
person experiences agony from one second to six months.
The patient may report typical symptoms of distress, but they have persisted for at least six
months. Due to the patient experiencing these symptoms for more than six months, the nurse
may observe social and familial relationship disruption, irritability, depression, a "beaten"
appearance, exhaustion, or somatic preoccupation.
There are numerous causes of chronic pain, including musculoskeletal disorders such as back
pain, treatment-related therapies such as chemotherapy, and pregnancy.
This nursing care plan for chronic back pain includes a nursing diagnosis, nursing interventions,
and nursing objectives.
What are intentions for geriatric care? How is a nursing care plan developed? Which nursing
care plan literature would you recommend to assist in the creation of a nursing care plan?
Care Plans are frequently developed in various formats. The format is not always crucial, and the
format of care plans may vary between nursing institutions and medical employment. Some
hospitals may display the information digitally or utilize pre-made templates. The most essential
aspect of the care plan is its content, as it will serve as the basis for your care.
Nursing Care Plan for Chronic Pain
Please observe the video below for a tutorial on how to construct a care plan in nursing school.
Otherwise, please continue down to view the finished care plan.
Scenario
A 56-year-old male presents with complaints of back discomfort. He states that he has
experienced consistent lower back pain for the past year. He explains that he decided to come in
to have it "checked out" because it is "taking a toll" on his ability to function. He reports that the
back pain has left him despondent and exhausted because he cannot perform the same tasks he
did a year ago. He also reports that his relationship with his wife and children has been affected.
You observe that the patient appears fatigued with dark circles under his eyes and is frequently
rubbing his back.

2. Nursing Diagnosis
Inflammation of the lumbar spine is the cause of the patient's one-year history of consistent
lower back pain, disruption of social and familial relationships, depression, fatigue, a "beaten
look," and rubbing of the painful area.
Subjective Data
He states that he has experienced consistent lower back pain for the past year. He explains that
he decided to come in to have it "checked out" because it is "taking a toll" on his ability to
function. He reports that the back pain has left him despondent and exhausted because he cannot
perform the same tasks he did a year ago. He also reports that his relationship with his wife and
children has been affected.
Objective Data
A 56-year-old male presents with complaints of back discomfort. You observe that the patient
appears fatigued with dark circles under his eyes and is frequently rubbing his back.
Nursing Outcomes
-At the next follow-up appointment, the patient will report an improvement in back pain and an
increase in daily activities.
-The patient will verbalize his expectations regarding the course of pain treatment and his
intended treatment outcomes and objectives.
-The patient will identify five noninvasive pain relief methods to aid in pain management.
-The patient will be instructed verbally on how to take the back pain medication prescribed for
him as needed.
Nursing Interventions
At the next follow-up appointment, the nurse will evaluate the patient's report of reduced back
pain and an increase in daily activities.
-The nurse will evaluate the patient's expectations regarding the duration of pain treatment and
his desired treatment outcomes.
-The nurse will educate the patient on five noninvasive pain relief techniques to aid in pain
management.
-The nurse will instruct the patient on how to take the back pain medication prescribed for him as
needed.

3. SAMPLE Block format Soap Note
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on
social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different
occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago and sometimes it is
accompanied by dizziness. He states that he has been under stress in his workplace for the last
month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS:

4. CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies
history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in
vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or
drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,
hoarseness, difficulty swallowing.
Respiratory: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty
starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20,
PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no
tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,
or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary
sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without
lesions,.Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling
or masses.

5. Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2
sec.
Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered
pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on
auscultation.
Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all
four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no
rebound no distention or organomegaly noted on palpation
Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no
stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Assessment
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure
(156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,
such as renal, adrenal or thyroid, this diagnosis is confirmed.
Differential diagnosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kidney disease (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Diagnosis is based on the clinical evaluation through history, physical examination, and routine
laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage,
including evidence of cardiovascular disease.
These basic laboratory tests are:
· CMP
· Complete blood count
· Lipid profile
· Thyroid-stimulating hormone

6. · Urinalysis
· Electrocardiogram
Ø Pharmacological treatment:
The treatment of choice in this case would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
Ø Non-Pharmacologic treatment:
· Weight loss
· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat
dairy products with reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d
reduction in most adults
· Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record
on the next visit with her PCP
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart attack, and other problems.
· Patient was educated on course of hypertension, as well as warning signs and symptoms, which
could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes
understanding to all
Follow-ups/Referrals

7. · Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current
hypotensive therapy. Urgent Care visit prn.
· No referrals needed at this time.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Patient Assessment and Care Plan
Instructions to student:
1) Bring one copy of this packet with you to clinical each week.
2) Your instructor will inform you of the number of packets and the dates each packet is due.
They may have you complete only portions of or all of the packet.
3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a
Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.
4) If your instructor asks you to submit the packet electronically, then please record your answers
in bold or in a colored or lower case font. This helps us identify your answers more quickly.
PATIENT ASSESSMENT FORM
STUDENT NAME: DATE:
CLIENT INITIALS: ROOM # DOB: AGE
GENDE
R:
ADMISSIO
N DATE:
CODE STATUS: ALLERGIES:
MARITAL
STATUS:
OCCUPATIO
N
(FORMER):
MEDICAL DX:
CHIEF
COMPLAINT
:

8. PAST HISTORY
(SURGERY/PROCEDUR
ES) WITH DATES
ORDERS
RATIONAL
E (Why is
this ordered
for this
client???)
EXAMPLE: DIET
2 g Sodium
diet with
nectar thick
liquids only
Sodium is
restricted due
to edema in
the bilateral
lower
extremities
and nectar
thick liquids
due to
dysphagia
from a past
stroke.
DIET
ACTIVITY
I/O
VS
BGM
FOLEY
NG
PEG/PEJ TUBE
WOUND CARE
RESPIRATORY
TREATMENT
TRACHEOSTOMY
SUCTIONING
CHEST TUBE
SPECIAL EQUIPMENT
LAB ORDERS
OTHER
REHAB SERVICES
ACTIVITY
OR
RATIONAL
E

9. TREATMEN
T PLAN &
SCHEDULE
PHYSICAL THERAPY
SPEECH THERAPY
OCCUPATIONAL
THERAPY
....../ 5 pts
IVs
IV FLUID AND RATE: SITE LOCATION AND CONDITION:
LAST DRESSING CHANGE: LAST TUBING CHANGE:
GAUGE: REASON FOR IV ACCESS:
DIAGNOSTIC
TESTS:
DATE RESULTS
REASON FOR TESTING AND
IMPLICATIONS FOR NURSING CARE
LAB
TEST
DATE RESULTS
NORMS
REFERENCE
RANGES
IMPLICATIONS FOR NURSING CARE
(WHAT S&S I SHOULD BE AWARE OF
AND WHAT YOU CAN DO TO HELP
IMPROVE AN ABNORMAL RESULT?)

10. GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s
Stages of Development)
CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO
HAVIGHUSRT
TASKS OF THIS
STAGE:
ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF
TASKS
...../ 5 pts
MEDICATIONS
If your client has more than 12 medications, select the 12 medications that are most important,
most frequently given or those that pertain to the client’s most significant medical problems. See
the example below.
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Coreg (carvedilol)
3.125 mg – 50 mg BID Asthma, heart block
Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions
β-adrenergic blocker
6.25 mg p.o. BID
Bradycardia, CHF,
thrombocytopenia,
hyperglycemia, bronchospasm
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching

11. He has a history of hypertension
but has been taking Coreg for 2
years to control his hypertension
BP’s for past 3 days have
been 128/78, 132/72, 138/80
How is this medication
impacting your client??B/P
readings, lab results, pain
management, etc……..
Do not discontinue abruptly or
before surgery
Caution with Upper airway
dysfunction
Rise slowly to minimize
orthostatic hypotension, check
B/P and heart rate prior to
administration
Take before meals
#1 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route &
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#2 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
#3 Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions

12. Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#4 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#5 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching

13. # 6 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#7 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#8 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions

14. Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#9 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#10 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching

15. #11 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
#12 Brand Name and Generic
Name
Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
...../ 20 pts
NURSES NOTES FOR CLINICAL

16. For this clinical, we are having you write out your assessment findings in the form of a narrative
nurse’s note. We have provided some samples of assessments. We have also provided a
worksheet that you may use to take into a patient’s room to take notes during your assessment.
Record your vital signs and type your physical assessment findings. This form will expand to fit
your typing. A sample of charting for a long
resident follows below.
TEMP: APICAL HR: RESP: BP: HT: WT:
DATE / TIME
(TYPE HERE)
Sample Narrative Note --- Head to Toe format
Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145
12/22/2010
1400
Resident in semi-fowlers position in bed. Pressure reduction mattress in place.
Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and
remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light
and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with
sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear
without erythema or exudate. No chewing or swallowing difficulties. 75% of
general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic
turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal.
Motor and sensory functions grossly intact. No weakness or paralysis. Upper
extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine
resting tremor in the left hand” No involuntary movement or abnormal posture.
Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and
intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and
PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion.
Apical pulse regular (rate) and rhythm. Double lumen picc line note to left
antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing
change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active

17. x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this
morning, passed a large, soft- formed brown stool and a moderate amount of clear
yellow urine. Bilateral lower extremities, no tenderness, swelling or joint
deformities noted. Denies numbness or tingling to extremities. Toe nails thick and
yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses
palpable and equal bilaterally.
PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down
your assessment findings.)
ROUTINE FINDINGS PATIENT VARIATIONS/ABNORMALS
COGNITION/NEUROLOGICAL (SAMPLE)
Alert and oriented x3, recent and remote
memory intact. Denies any numbness or
tingling to extremities”
(SAMPLE) “Fine resting tremor of left hand
SKIN
SENSORY
Wound measurements and complete
description if available at the very least
Document dressing including the type of
dressing and description of condition!
BREASTS - DEFERRED.
RESPIRATORY –
(Include ventilator settings as indicated in
narrative note)
CARDIOVASCULAR
Include any vascular access device, IV lines,
AV fistulas, perma -cath lines, etc.
ABDOMEN –
.
Include any enteral feedings here and route
BOWEL CONTINENCE? LAST BM?
BOWEL PLAN?

18. MUSCULOSKELETAL -
GENITOURINARY -
URINARY CONTINENCE? TOILETING
PLAN?
PELVIC -
DEFERRED.
RECTAL - DEFERRED.
....../ 10 pts
NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at
least 10) and then identify an appropriate nursing diagnosis that you can think of that would
apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and
then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be
priority 1, 2, or 3!!!!!
Expectation is to have at least 10 nursing diagnosis listed!
#
List the Client
problem
An appropriate
Nursing Diagnosis
stem
(REFER TO YOUR
NURSING
DIAGNOSIS LIST)
Related to part of the
statement (This is
individual to your
client)
As evidenced by part of the
statement (This is
individual to your client)
REMEMEBR THIS IS
NOT USED IN A “Risk
For” diagnosis
1
SAMPLE:
Reports severe
pain in the right
hip.
“Acute Pain”
“related to” fractured
right hip
“as evidenced by” verbal
report of pain rated at an 8
on a scale of 0 –to 10.
2
SAMPLE:
Complete bed rest
“Risk for Impaired
skin integrity”
“related to “
immobility
NONE it is a “Risk for”
diagnosis so there is no
evidence statement

19. From the list above your faculty member will give you direction regarding how many and which
diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.
SAMPLE NCP
NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED
BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal
report of pain rated 8 on a scale of 0 -10.
ASSESSMEN
T
(Data that
directly
pertains to the
above nursing
diagnosis)
OUTCOME
STATEMEN
T
(Patient
centered,
realistic,
specific,
measurable,
target time)
INTERVENTIONS
(Individualized,
specific, frequency)
Minimum of 4-5
interventions per plan
SCIENTIFIC
RATIONALE
(Supporting statement
from text or other
source, cite source)
EVALUATIO
N OF
OUTCOME
(Met, partially
met, unmet,
unknown by
target time)
SUBJECTIVE
DATA: “My
right hip hurts
me so much
every time I
move. I am so
afraid to start
physical
therapy”
SHORT
TERM:
Client will
report pain
level rated at
a 3 or lower
30 minutes
after pain
medication
taken
1. Educate the client on
the importance of pain
relief to enhance her
rehabilitation efforts
and include education
on various types of
methods to relieve pain.
2. Encourage client to
express any questions
or concerns she may
have regarding pain
management methods
1. “There are many
ways to manage pain. In
addition to
pharmacologic and non-
pharmacologic
measures, simple
nursing interventions
can alter patients’ pain
experience and speed
their recovery.” Taylor,
Lillis and White pg.
1168.
2. “Common fears
include a loss of control
Short Term
Goal: Met;
pain was rated
at a 2 on a
scale of 0 to 10
after
administration
of Vicodin.

20. to alleviate anxiety and
fears.
3. Educate the client on
her responsibility to
honestly report pain
when it occurs as well
as reporting if the
current pain
management is
effective or ineffective
for providing her pain
relief
4. Provide for
alternative/complement
ary measures of pain
relief, such as, reduce
lighting and noise,
soothing music, pet
therapy, massage, and
hot/cold packs
according to client
preferences.
and embarrassment by
being unable to deal
with pain maturely…
The patient may view
the need of for
medication as a sign of
weakness or may fear
addiction or loss of
effectiveness at a later
date.” Taylor, Lillis and
White pg. 1169.
3. “As a patient
advocate, ensure that a
strong emphasis on the
need for aggressive,
individualized strategies
that can minimize or
eliminate acute pain and
improve patient
outcomes. Preventing
pain is easier then
treating it once after it
occurs.” Taylor, Lillis
and White pg. 1178.
4.
Alternative/complement
ary measures will
provide an added benefit
of distraction from pain
experience and augment
analgesic effect.
Cold/hot therapy can
provide constriction and
or dilation which will
reduce pain
inflammation in each
specific circumstance
Daniels. Pg 378
Long Term
Goal. In
progress

21. OBJECTIVE
DATA:
Alert and
oriented 70
year old
widowed
female. Lives
in an
apartment
independently.
2 daughter live
nearby and
visit often.
History of a
fall while out
shopping 1 ½
weeks ago.
Right hip
surgically
repaired 7
days ago.
Surgical
dressing to
right hip is
clean, dry and
intact.
Circulation,
motion and
sensation
intact to right
lower
extremity.
Afebrile; BP
124/80; R-18
AP 84 and
regular. 5 foot
7 inches
weighs 142
pounds. No
hearing
deficits; wears
eye glasses
LONG
TERM:
Client will
report pain
level of 2 or
less using
ibuprofen
with
alternative
pain control
methods by
discharge.

22. Medical
history
positive for
osteoarthritis
and
osteoporosis
Non weight
bearing to
right leg and
to use a
walker for
ambulation
To start
physical
therapy for
gait and
strength
training BID
times 7 days
and
occupational
therapy to
develop upper
body strength
once daily
times 7 days
Reports pain
level is at 8 on
a scale of 0 to
10.
Has Vicodin
5mg/325 mg
po 2 tabs
every 4 hours
prn for severe
pain
Ibuprofen 400
mg every 6
hours prn for
moderate pain.

23. Short term outcome: An outcome that can be accomplished by the end of the student clinical day.
Interventions: Each nursing intervention must come from a reliable nursing reference or source.
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.
Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)
NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED
BY STATEMENT:
ASSESSMENT
(Data that directly
pertains to the
above nursing
diagnosis)
OUTCOME
STATEMENT
(Patient centered,
realistic, specific,
measurable,
target time)
INTERVENTIONS
(Individualized,
specific, frequency)
SCIENTIFIC
RATIONALE
(Supporting
statement from
text or other
source, cite
source)
EVALUATION
OF OUTCOME
(Met, partially
met, unmet,
unknown by
target time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:
Short term outcome: An outcome that can be accomplished by the end of the student clinical day.
Interventions: Each nursing intervention must come from a reliable nursing reference or source.
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.
Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)
...../30

24. NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED
BY STATEMENT:
ASSESSMENT
(Data that directly
pertains to the
above nursing
diagnosis)
OUTCOME
STATEMENT
(Patient centered,
realistic, specific,
measurable,
target time)
INTERVENTIONS
(Individualized,
specific, frequency)
SCIENTIFIC
RATIONALE
(Supporting
statement from
text or other
source, cite
source)
EVALUATION
OF OUTCOME
(Met, partially
met, unmet,
unknown by
target time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:
Short term outcome: An outcome that can be accomplished by the end of the student clinical day.
Interventions: Each nursing intervention must come from a reliable nursing reference or source. .
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.
Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)
..../30
NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED
BY STATEMENT:
ASSESSMENT
(Data that directly
pertains to the
OUTCOME
STATEMENT
INTERVENTIONS
(Individualized,
specific, frequency)
SCIENTIFIC
RATIONALE
EVALUATION
OF OUTCOME

25. above nursing
diagnosis)
(Patient centered,
realistic, specific,
measurable,
target time)
(Supporting
statement from
text or other
source, cite
source)
(Met, partially
met, unmet,
unknown by
target time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:
Short term outcome: An outcome that can be accomplished by the end of the student clinical day.
Interventions: Each nursing intervention must come from a reliable nursing reference or source. .
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.
Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)
................/30
Key Problem: Impaired urinary elimination
Data:
Intake=3800 Output=3200
Polyuria
3+ glucose in urine
AEB: Polydipsia and polyuria
Outcomes:
Pt. will have urine output of 1000 – 2000 ml/24 hours.
Interventions:

26. Monitor I & O q shift.
Monitor BGM a.c. and h.s.
Monitor kidney function tests
Administer antihyperglycemics as ordered.
Key Problem: Knowledge deficit
Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine
AEB: Verbal statements and questions.
Outcomes:
Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique
by discharge.
Interventions:
Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style.
Provide information q shift according to teaching plan recorded in EMR and document pt’s
response.
Reassess level of knowledge daily.
Provide written information.
Provide educational resources available in the community.
Medical Problems (Pathophysiology)/Surgical Procedures:
Newly diagnosed diabetic
Key Assessments:
S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals
Tests: FBS, hemoglobin A1C
“I don’t know how this fits”

27. Recent widow
Kids live out of state
? support system
Key Problem: Acute anxiety
Data: Restless, verbally states she is anxious.
AEB: Pt states “I don’t know what I will do with diabetes, this is too much.”
Outcomes: Pt. will verbalize under-standing of resources available by discharge.
Interventions:
Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions.
Demonstrate progressive relaxation exercises and have pt. return demonstrate.
Provide pt. with a list of community resources for newly diagnosed diabetics.
Identify client’s perception of anxiety
Utilize empathy.
Past Medical History: Hypertension x 20 years; appendectomy at age 9.
Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary
lifestyle; 290 pounds, age 52
Key Problem:
Imbalanced nutrition, more than
Data:
BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs
AEB: Anthropometric measurements.
Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior
to discharge.
Interventions:

28. Assess client’s knowledge of nutrition and its relationship to diabetes.
Arrange for dietary consultation.
Reinforce teaching by dietician.
Encourage physical activity as a weight loss strategy.
Provide pt with community resources that can assist her with weight loss goal.
“I DON’T KNOW HOW THIS FITS”
PAST MEDICAL HISTORY
RISK FACTORS
MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:
KEY ASSESSMENTS:
Key Assessments:
Tests:
KEY PROBLEM:
DATA:
AEB:
OUTCOMES:
INTERVENTIONS:

29. KEY PROBLEM:
DATA:
AEB:
OUTCOMES:
INTERVENTIONS:
RUBRIC for Grading Packets
/60pts
KEY PROBLEM:
DATA:
AEB:
OUTCOMES:
INTERVENTIONS:
KEY PROBLEM:
DATA:
AEB:
OUTCOMES:
INTERVENTIONS:
Student Name: Clinical Date: Site:
Section Grading Criteria
Satisfactory Or
Unsatisfactory
Comments,
Kudos,
Things to
Improve for
Next Time

30. 10 points
Patient Demographics,
Diagnoses, Surgeries,
Orders, Rehab, IV,
Imaging and Lab
Page 1 fully and correctly
completed 5 pts
Page 2 fully and correctly
completed 5 pts
_/5___
_/5___
20 points
Medications
Medication Trade Name 2 pts
Medication Generic Name 2 pts
Pharmacological Classification 2
pts
Normal Dosage Range 2 pts
Dose ordered 2 pts
Route and Frequency 2 pts
Contraindications 2 pts
Adverse Effects/Reactions 2 pts
Nursing Considerations & Teaching
2 pts
(Legible or typed) 2 pts
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
_/20__
10 points
Narrative Notes
Head-to-Toe
Assessment
Narrative note is in Head to Toe
order
Head-to-toe assessment
documented Abnormal results
noted 10 pts Nursing Care Plan and
Diagnosis for Chronic Pain
___/10_
60 points (either a
Concept Map or a
Patient Care Plan)
Concept Map
Correct Medical Diagnosis 15 pts
Pathophysiology 15 pts
Key Assessments 15 pts
____/60
OR

31. At least 3 problems identified 15
pts
Nursing Care Plan and Diagnosis
for Chronic Pain
60 points (either a
Concept Map or a
Patient Care Plan)
Patient Care Plan
3 nursing diagnoses Related to”
“As evidenced by” 18 pts
2 Outcomes specific, measurable,
timed 8 pts
4-5 Interventions are logical,
appropriate 15 pts
4-5 Scientific Rationales supporting
each intervention 15 pts 2
Evaluations 4 pts