Comprehensive Care Plan Template (patient-focused plan of care)
Team #/Class Day:
Team Member Last names:
STUDENTS SHOULD REFER TO THE PROJECT RUBRIC IN CANVAS FOR SPECIFIC DETAILS AND GRADING
NURSING EXPECTED PATIENT NURSING INTERVENTIONS RATIONALE AND INCLUSION OF CONCEPTS
DIAGNOSES OUTCOMES INDIVIDUALIZING TO OF LECTURE TOPICS
THIS PATIENT
LIST IN PRIORITY S. M. A. R. T. ACTIONS BY THE NURSE THAT SUPPORT HOW DOES THIS INCLUDE HERE HOW YOU
ORDER WITH #1 FORMAT OR ASSIST THE PATIENT IN MEETING INTERVENTION SUPPORT INCORPORATED COURSE
BEING THE THE EXPECTED OUTCOMES OR ASSIST THE PATIENT IN CONCEPTS—CLEARLY
HIGHEST MEETING THE EXPECTED EXPLAIN APPLICATION OF
PRIORITY OUTCOME? COURSE CONCEPT
RELATED TO
INTERVENTIONS
INCLUDE 3 THINK: “THE THINK, “THE NURSE WILL (VERB)…” EVERY INTERVENTION EACH COURSE CONCEPT
PARTS FOR ALL PATIENT WILL MUST INCLUDE A MUST BE INCLUDED AT
“ACTIVE” (VERB)…” RATIONALE AND PATIENT LEAST ONCE IN ENTIRE
DIAGNOSES AND INDIVIDUALIZATION. PLAN OF CARE, NOT FOR
2 PARTS FOR ALL INDIVIDUALIZING MAY OR EACH ND
“RISK FOR” MAY NOT DIRECTLY
DIAGNOSES RELATE TO INCLUSION OF
A COURSE CONCEPT.
#1 Technical/Assessment Rationale
Reviewed, January 8, 2020
Comprehensive Care Plan Template (patient-focused plan of care)
Delayed Surgical ST Goal – The patient 1. Patient will be given antipyretic
Recovery r/t will reduce his fever medication on a scheduled
gallbladder to less than 100.4 F basis.
removal, as by the end of the
2. The wound will be thoroughly
evidence by day.
assessed for improved healing
yellow exudate
LT Goal – Upon and lack of infection after
drainage from
discharge, the every dressing change.
the wound,
patient’s abdomen
wound 3.
will show evidence of
dehiscence at
healing that is free of Interpersonal/Actions Rationale
the lower end of
exudative fluid with
his incision, and
surrounding tissue 1. Patient will be given clean
fever proven by
intact. Indicated by wound dressings.
a temperature of
open wound
101.2 F. 2.
appearing red and
beefy. 3.
Cognitive/Teaching Rationale
1. Patient will be given education
on wound care.
2.
#2 ST Goal – The patient’s Technical/Assessment Rationale
self-reported pain will
Acute pain r/t to decrease to a level of 1. The patient will be asked to
post-operative report pain using the numeric
Reviewed, January 8, 2020
Comprehensive Care Plan Template (patient-focused plan of care)
gallbladder less than 4/10 within 2 pain scale on a level from 1-10
removal as hours of care. Patient’s every three hours.
evidenced by vital signs will be WDL
patient stating he by the next morning 2. Observe breakthrough pain
“does not feel assessments. and for nonverbal cues of pain
well,” high every two hours.
respiratory rate of
28 respirations, 3. Monitor patient’s vital signs
LT Goal – The patient
high pulse rate of will report post-
every two hours.
108 bpm and the discharge pain to the
patient’s refusal to Interpersonal/Actions Rationale
provider that is greater
take pain than 4/10 even with use 1.
medications. of pain medication
2.
3.
Cognitive/Teaching Rationale
1.
2.
#3 ST Goal – The patient Technical/Assessment Rationale
will get OOB to perform
Ineffective Health mobility with 1.
Maintenance r/t supplemental oxygen
refusal to and assistance if
2.
participate in needed every 4 hours.
postoperative 3.
Patient will begin a
Reviewed, January 8, 2020
Comprehensive Care Plan Template (patient-focused plan of care)
management,as protein-rich diet by Interpersonal/Actions Rationale
evidenced by “I selecting two protein-
don’t care about rich foods to 1. Build rapport and develop
getting better” and incorporate by the start trust with the patient by
refusal to take of the next meal. communicating with the
therapeutic drugs. patient consistently
LT Goal – Upon
throughout the day
discharge, the patient
will take all pain and 2.
antibiotic medications
as prescribed for the 3.
duration of the
prescription. Cognitive/Teaching Rationale
1. Verbally educate the patient
on the consequences of not
taking pain medication and
antibiotics
2.
References:
Reviewed, January 8, 2020
