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UNIVERSAL NURSING CARE PLAN FORM
Rasmussen University
STUDENT NAME: ______________________________________________________ DATE: ____________________________
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Rasmussen Universal Care Plan
Demographics
Client Initials: ________________________ Room #: _________ Age: _____ Sex: _____
Race: ________________
Language: ________________ Religion: ________________________ Marital Status: ______________
Allergies: ____________________________________________
Vitals: T ____________ P ____________ B/P ____________ RR ____________ 02 SAT ____________ Pain Scale ____________
Chief Complaint:
History of Present Illness:
Personal History:
Work History:
Advanced Directive:
Additional Notes
Mental Status/Orientation:
A&Ox4: Self/Place/Time/Situation:
Attending
General Appearance (grooming, posture, dress):
Consults
Cultural beliefs:
Memory:
Recent_________________ Remote: __________________
Behaviors: □ Nicotine □ Alcohol □ Drugs □ THC □ Other
Identify a QSEN Concept you addressed or utilized today. Give a brief explanation of how this concept was used in your patient’s care.
QSEN Concept: _________________________________ (Patient Centered-Care, Teamwork & Collaboration, EBP, Quality Improvement, Safety)
Weekly focus
Professionalism Daily!
Pathophysiology of Diagnosis
Explanation of Medical Diagnosis:
Textbook Signs and Symptoms:
Recommended Treatments:
Teaching/Prevention:
Page 1 of 9
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
S
SBAR/Report
Adm Dx:
Attending:
Consults:
Rasmussen Universal Care Plan
Chief complaint:
Allergies
Code Status: □ Full □ DNR □ DNI □ AND
Isolation: ____________________________
PMH:
B _______________________________________________________
Behaviors: □ nicotine □ Alcohol □ Drugs □ THC □ Other
A Neuro: A&O x_____/Confused Speech: _____________ Dysphagia: _______________
Decreased sensations: □ RUE □ LUE □ RLE □ LLE □ seizures
HEENT: Hearing: □ Left ear □ Right ear □ Both
Vision: □ Left eye □ Right eye □ Both
Oral Mucosa: ___________ Teeth:
Respiratory: Breath Sounds RUL ______ LUL ______ RLL _______ LLL ________
Cough: □ None □ Productive □ Non-Productive
Respirations: □ Labored □ Unlabored
Oxygen: Liters _____________
Cardiac: Heart Sounds □ S1 S2 □ rate/rhythm ______________ □ Other: ___________
Edema: ______________________
Vascular: □ Cap refill □ Peripheral pulses
□ SCDs
Telemetry: BX#_____ Rhythm _________
Gastro: Bowel Sounds: □ Normal □ hyperactive □ hypoactive □ G-Tube □ Ostomy
Abdomen: □ soft □ firm □ distended □ tender □ N/V □ last BM ____________
□ continent □ incontinent □ bladder distention □ retention
□ Foley Please indicate why? ___________________________________________
Integumentary: □ warm/cool □ clammy/dry □ turgor
□ Wounds / decubitus ulcer Location: _________________
Genitourinary:
Dressing orders:
Musculoskeletal: Gait □ Steady □ Unsteady
□ Ad Lib □ Bed rest □ Assist x 1 x2
R
Discharge Plan:
Discharge Needs:
Discharge Teaching:
Page 2 of 9
ROM □ Full □ Limited □ Urine COCA
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Psychosocial:
_________________
_________________
Abnormal Labs
CBC
COAG
Electrolytes
RBC
PT
Sodium
Pain: level _______
Location: ________
Last pain med:
________________
Hgb
aPTT
Calcium
HCT
PTT
Magnesium
WBC
INR
Chloride
ESR
Platelets
Potassium
Diet: ____________
□ fluid restrictions
_______ml/______
□ strict I&O
Daily wt.: ________
ABGs
Lipids
Phosphorus
pH
Cholest.
Urinalysis
PaCO
LDL
Spec. Gravity
PaO
HDL
Protein
HCO3
Triglyc.
Glucose
Venous Access
Site _____________
Gauge ___________
Rate ____________
□ PIV □ PICC
Liver
Renal
Ketones
Albumin
BUN
Urine pH
Ammonia
Creatinine
Urine WBC
Bilirubin
Creat Clr
Therapeutics
□ Midline □ IJ/EJ
□ Midline
Drains:
□ chest tube
Protein
Digoxin
Cardiac
Phenobarbital
Trop1
Theophylline
Trop 2
Phenytoin
Trop 3
Lithium
□ JP/suction
□ Wound
Precautions:
□ Contact
□ Droplet
□ Aspiration
□ Fall (sitter/Bd alarm)
□ Bed/Chair
T
P
RR
B/P
O2
Blood
Sugar
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Rasmussen Universal Care Plan
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Medications
Drug
Page 3 of 9
Dose
Route
Class
Action
Adverse Effects
Why is your patient on this medication?
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Rasmussen Universal Care Plan
Island Interventions
Care Planogram Worksheet
2
PES
Based on your assessment, what interventions can you do as
a nurse for each s/s before getting the physician’s orders?
You and your patient are stranded on
an island, looking at your patient’s
diagnosis, what could you do to keep
them alive.
1.
Problem/Diagnosis
Diagnosis:
Etiology/Cause:
3.
Signs & Symptoms
5.
2.
4.
6.
7.
1
3
Complete the lines with your assessment S/S or expected
findings for a patient with this problem/diagnosis.
Based on the interventions you
chose, which are the most
important to implement first?
4
8.
List what orders you can anticipate
from the physician?
5
What are the outcomes of your
interventions and the
implementation of physician orders?
1.
2.
3.
4.
5.
Subjective Data?
Page 4 of 9
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Rasmussen Universal Care Plan
NURSING DIAGNOSESMINIMUM OF 6 Diagnoses
Nursing
Diagnosis
Definition of
Diagnosis
Related to
As Evidenced By
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
(Form #1)
Rationalization for Prioritization
(in your own words)
Why is this dx your #1 concern?
1
Why is this dx your #2 concern?
2
3
4
5
6
Page 5 of 9
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Rasmussen Universal Care Plan
Nursing Care Plan Student Name: _________________________________________________ Date:
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
_______________________
(Form #2)
Client Initials: ___________________________ Patient Medical Diagnosis: _________________________________________________
Nursing Diagnosis: PES: Diagnosis ____________________________________________ related to ____________________________________
Problem/Diagnostic label approved by NANDA-I
Etiology/Causation
as evidenced by _________________________________________________.
*Do not use Falls, Pain, Knowledge deficit or Risk of.
Instead, use the cause of fall or the pain. For “risk of,” choose items that have actually occurred because risk have not happened, if ever.
Signs/Symptoms/defining characteristics
Assessment
Include at least 3 subjective
and/or objective data that lead
to the nursing diagnosis.
Diagnosis
Diagnosis
Using the PES statement format,
Write out the entire diagnostic
statement (problem R/T etiology
AEB signs & symptoms)
Planning
Diagnosis
Plan
Two statements are required for
each nursing diagnosis. It should
be patient/family focused. Must
be in “SMART” form to include
Implementation
Diagnosis
Plan InterventionEBPDiagnosis
Rationale
Plan Intervention
Evaluation
Reassessment
Diagnosis
Plan Intervention
EvaluationD
List at least 3 nursing
interventions you could do as the
nurse. Do not include physician
orders. WHAT WILL YOU DO?
The rationale with in-text citation
is proof of evidence-based
practice for the intervention you
chose. Use in-text citation for
each intervention
How would you revise your plan
based on your patient’s needs or
response to your current plan?
1.
1.
Short-term goal outcome
Specific, Measurable, Attainable, Relevant,
and Timely information.
Subjective:
1.
Statement #1
(Short-term goal)
2.
2.
3.
3.
1.
1.
2.
____Met
____ Partially Met
____ Not Met
Describe:
[on (date) at (time) pt…]
.
3.
Objective:
1.
Statement #2
(Long-term goal).
2.
2.
3.
3.
2.
3.
Page 6 of 9
Reassessment Statement:
[going forward, WHAT will be
assessed, WHEN and by WHOM?]
Long-term goal outcome
____Met
____ Partially Met
____ Not Met
[on (date) at (time) pt…]
Reassessment Statement:
[going forward, WHAT will be
assessed, WHEN and by WHOM?]
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Rasmussen Universal Care Plan
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Nursing Care Plan Student Name: _________________________________________________ Date:
_______________________
Client Initials: ___________________________ Patient Medical Diagnosis: _________________________________________________
(Form #2)
Nursing Diagnosis: PES: Diagnosis ____________________________________________ related to ____________________________________
Problem/Diagnostic label approved by NANDA-I
Etiology/Causation
as evidenced by _________________________________________________.
*Do not use Falls, Pain, Knowledge deficit or Risk of.
Instead, use the cause of fall or the pain. For “risk of,” choose items that have actually occurred because risk have not happened, if ever.
Signs/Symptoms/defining characteristics
Assessment
Include at least 3 subjective
and/or objective data that lead
to the nursing diagnosis.
Diagnosis
Diagnosis
Using the PES statement format,
Write out the entire diagnostic
statement (problem R/T etiology
AEB signs & symptoms)
Planning
Diagnosis
Plan
Two statements are required for
each nursing diagnosis. It should
be patient/family focused. Must
be in “SMART” form to include
Implementation
Diagnosis
Plan InterventionEBPDiagnosis
Rationale
Plan Intervention
Evaluation
Reassessment
Diagnosis
Plan Intervention
EvaluationD
List at least 3 nursing
interventions you could do as the
nurse. Do not include physician
orders. WHAT WILL YOU DO?
The rationale with in-text citation
is proof of evidence-based
practice for the intervention you
chose. Use in-text citation for
each intervention
How would you revise your plan
based on your patient’s needs or
response to your current plan?
1.
1.
Short-term goal outcome
Specific, Measurable, Attainable, Relevant,
and Timely information.
Subjective:
1.
Statement #1
(Short-term goal)
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
____Met
____ Partially Met
____ Not Met
Describe:
[on (date) at (time) pt…]
.
3.
Objective:
1.
Statement #2
(Long-term goal).
Reassessment Statement:
[going forward, WHAT will be
assessed, WHEN and by WHOM?]
Long-term goal outcome
____Met
____ Partially Met
____ Not Met
[on (date) at (time) pt…]
2.
3.
Page 7 of 9
Reassessment Statement:
[going forward, WHAT will be
assessed, WHEN and by WHOM?]
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Rasmussen Universal Care Plan
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
This sheet must be typed, no exceptions!
Universal Care Plan APA Reference Page
Page 8 of 9
V03/23
RASMUSSEN-FORT MYERS SCHOOL OF NURSING
CLINICAL CLASS _________________________
CLIENT’S ADMITTING DX: __________________
Care Plan Rubric
Rasmussen Universal Care Plan
STUDENT NAME: _______________________________
TODAY’S DATE_________ CARE DATE _____________
ROOM # ___________ CLIENT INITIALS _____________
Demographics (Pg 1), SBAR/Report Sheet (Pg 2),
Medications (Pg 3) Care Planogram (Pg4)
Form 1: Nursing Diagnoses (Pg 5)
-Includes all information required in the header (name, dx, doc, client rm #/init)
-6 ( six) minimum, appropriate to the individual client
-Is properly stated (Actual-used P r/t
A.E.B.
format, using the provided NANDA list (NO Pain, NO
Knowledge Deficits, NO Risk-For’s please)
-Reflects a situation which the nurse can order interventions to treat or prevent
Form 2: NURSING PROCESS REPORT FORM (Pg 6)
Care Plan (Top 2 Priority Dx)
Assessment-Data (Subjective and Objective) (Pg 6)
-Data is properly classified under these headings:
SUBJECTIVE DATA, OBJECTIVE DATA
-Data includes cues (no inferences)
-Data is appropriate/specific to validate the nursing diagnosis
-Data reflects a complete assessment of the client for the nursing diagnosis
Client Goal (Pg 6)
-Is a client goal
-Is realistic and attainable
-Is measurable (S.M.A.R.T. goals: Specific, Measurable, Attainable, Relevant, Timed)
-Is properly stated (Includes subject, action verb, performance criteria and target date/time)
-Does not interfere with other client therapies
-Considers client’s level of growth and development, and individuality
-Has a realistic time frame for achievement
Nursing Interventions Go to the Island (Pg 4) then complete (Pg 6 & Pg 7)
-3 Interventions minimum, per goal for a total of 6
-Concise and includes: an action verb, a descriptive phrase-how, what, where to perform the action, and a time
frame-exactly (when, how often, how long)
-Clearly stated so other personnel can carry out the orders without question or confusion
-Appropriate to the nursing diagnosis and client
-Consistent with the medical plan of care
-Adequate to achieve the client goal
-Are numbered consecutively
Scientific Rationale (Pg 6)
-Are clear, complete and support the use of the nursing interventions
-Source for each rationale is properly documented (Author’s last name, year, p. or pp.)
-Are numbered consecutively to match each nursing order
Evaluation/Client Goal (Pg 6)
-Evaluative statement includes whether the goal was met, partially met or not met using criteria stated in the
client goal statement
-Evaluative statement describes the client’s behavior which indicates the goal was met, partially met or not met;
and date/time of eval
-Includes a Reassessment statement (going forward – what, when, and by whom)
Reference List (Pg 8)
-Completed according to APA format, TYPED, Use the Textbooks, No Websites.
-Includes spelling and grammar for entire care plan
TOTAL POSSIBLE POINTS
Page 9 of 9
4
4
2.5
3.5
4
1.5
3.5
1
24
V03/23
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