CarePlanTemplate4.docx

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    CLINICAL APPLICATION OF THE NURSING PROCESS TOOL

    Name _________________________

    Course _________________________

    Instructor _________________________

    Client’s initials:__________ Actual Developmental Stage: _________________________

    Gender: _____ Age: _____ Perceived Developmental Stage: _______________________

    Reason for admission (if applicable) _____________________________________________

    Analysis (nsg.dx)

    Expected Outcomes

    (client goals)

    Implementation

    (nursing interventions)

    Rationales

    (Why? w/ references)

    Evaluation

    (of goals)

    Scoring Code KeyStudent Name: _____________________

    S – Satisfactory

    NI – Needs Improvement

    U – Unsatisfactory

    Please submit this scoring criterion with the Care Plan.

    Area to be scored

    Scoring code

    1. Analysis

    0. Determined basic needs of the client which are threatened

    0. Nursing Diagnosis are in priority order based on Maslow’s Hierarchy of Needs, and ABC’s (airway, breathing, circulation)

    All parts of the nursing diagnoses present and appropriate (Diagnosis statement, Related to (R/T) factors, patient specific – as evidenced by (AEB) subjective and objective (S / O) data)

    1. Plan

    1. Goals are appropriate (time specific, measurable, focused, realistic) and related to the Nursing Diagnosis

    1. Measures to accomplish goal are appropriate

    1. Rationale

    2. Uses scientific principles

    2. Reference sources are noted

    1. Implementation

    3. Nursing actions carried out are specific and appropriate for goal attainment

    1. Evaluation

    4. Describes clients responses to nursing interventions

    1. Determines the extent to which goals have been met

    (States goal attained, not attained or partially attained)

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