RLE 002

Cebu Normal University

College of Nursing Cebu City
Mission-Vision: Care Using Knowledge and Compassion Theory-based (Betty Neuman)

NURSING CARE PLAN

Assessment Diagnosis 3 points 3 points Goals Theoretical Basis 2 points 2 points Interventions Evaluation 4 points 1 point Bibliography 15 points

Name of Student:__________________________________________ Clients Initials:___________________________________________ Age:______Gender: _____Civil Status:________Religion:_______ Allergies: ________________________________________________ Diet:_____________________________________________________ Date of Admission:________________________________________ Diagnosis/Impression:_____________________________________ lifespan)

Stressor Classification: (Please check) ______ Physiological (body structure and functions) ______ Psychological (mental processes and emotion) ______ Socio-cultural (relationships, social expectations) ______ Spiritual (influence of spiritual beliefs) ______ Developmental (developmental processes over the

NURSING DIAGNOSIS
Assessment Subjective: Diagnosis

NURSING GOALS
Mutual Planning
(Goal attainable within the shift)

NURSING OUTCOME
Interventions
(with Rationale & Source)

Actual Evaluation

PRIMARY INTERVENTIONS Promotive:

Objective:

Preventive:

Theoretical basis:

SECONDARY INTERVENTIONS Curative

TERTIARY INTERVENTIONS Rehabilitative

Bibliography: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Nursing Care Plan Product Assessment Rubric

Score Criteria
Assessment Diagnosis

3
Cues are comprehensive and adequately substantiate the nursing diagnosis. It reflects the accurate interpretation of the subjective and objective data analyzed. Problem-Etiology (PE) format is observed.

2
Cues are comprehensive and inadequately substantiate the nursing diagnosis. The diagnosis selected reflects the adequate interpretation of the subjective and objective data analyzed but are not always the best choice from the possible diagnoses that could be interpreted from the data. PE format is used correctly. It sufficiently explained the nursing diagnosis. The identified goal reflects the timebounded measurable behavioral elements. The criteria identified generally are individualized and will lead to the control of the related factors that contribute to the nursing diagnosis. Interventions developed can be linked to specific outcomes but may be independent. The interventions may not be realistic and appropriate to the patient's current status.

1
Cues do not substantiate the nursing diagnosis. The diagnosis selected reflects that no effort to interpret information was applied resulting in a flawed plan of care. PES format is usually not complete or used correctly. It insufficiently explained the nursing diagnosis The identified goal barely reflects the time-bounded measurable behavioral elements. The criteria identified generally are individualized and will lead to the control of the related factors that contribute to the nursing diagnosis. Interventions developed are incomplete. Inappropriate interventions may be included in the plan of care.

0
No cues presented. No diagnosis identified.

Theoretical Basis Goals

No theoretical basis provided. No goal formulated.

Intervention s

Specific interventions can easily be linked to specific outcomes. The interventions are realistic and appropriate to the patient's current status.

Specific interventions can be linked to specific outcomes. The interventions are realistic and usually appropriate to the patient's current status.

No interventions to be implemented.

Evaluation

The subjective and objective data that measures the outcome is collected and analyzed correctly.

Subjective and objective data is selected to reflect evaluation without consideration of the outcome criteria. Data collection is not subjected to analysis. References

Bibliography

Updated

(within

5-10

years)

and

accurate references are provided.

provided are not updated and inaccurate.