CarePlanTipsandExamples1.pdf

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.