You are required to write a care plan for two different patients that you cared for in this clinical rotation.
You are required to write a care plan for two different patients that you cared for in this clinical rotation.
Purpose: Professional nursing requires the development of a formal plan of care. That Care Plan is the professional nurses’ prescription which
directs all nursing care. Professional nurses use the Nursing Process to develop Care Plans. While there are many different formats for Care
Plans, Iona nursing students will utilize the attached format.
You are required to write a care plan for two different patients that you cared for in this clinical rotation. You must achieve a
passing grade on each of the care plans.
Procedure: (One page will be used for each nursing diagnosis)
Nursing Diagnosis and Medical Diagnosis: document this information in the area provided
Document the patient’s INITIALS ONLY
Write up One priority nursing diagnosis. Write a different nursing diagnosis for your second care plan.
Subjective data: document the information that the PATIENT TELLS you. Document only that information which supports the Nursing Diagnosis
that you are addressing.
Objective data: document the information that YOU obtain from physical assessment. Document only that information which supports the
Nursing Diagnosis that you are addressing.
Measurable Goal: Write ONE short term patient oriented measurable goal for the Nursing Diagnosis. Nursing Interventions: List at least 5
Nursing Interventions necessary to fulfill this goal.
Evaluation: Identify the following:
Whether or not the goal was met
If the goal was met, what data supports that the goal was met?
If the goal was NOT met, what adjustments need to be made to the plan of care and why?
Rationale Document:
List the Nursing Intervention by number.
Provide evidence for each Nursing Intervention.
Provide the full citation for each rationale.
Answer preview:
word limit:450*2