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: Allergies: Diet:_ Date of Admission:_ Diagnosis/Impression: _

Religion:_

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 lifespan)

NURSING DIAGNOSIS
Assessment Diagnosis

NURSING GOALS
Mutual Planning

NURSING OUTCOME
Intervention s Actual Evaluation

Subjective:

PRIMARY INTERVENTIONS Promotive:

Objective:

Preventive:

Theoretical basis:

SECONDARY INTERVENTIONS Curative

TERTIARY INTERVENTIONS Rehabilitative

Bibliography:

Nursing Care Plan Product Assessment Rubric

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. ProblemEtiology (PE) format is observed.

Scor e 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 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.

Theoretical Basis Goals

Interventions Specifi c interventions can easily be linked to specific outcomes. The interventions are realistic and appropriate to the Evaluation

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

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

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

Bibliography

Updated (within 5-10 years) and accurate references are provided.

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