Clinical For Community And Public Health Nursing
Care Plan
Choose a community setting of your preference and create a patient scenario. Keep in mind this is a community and public health nursing clinical course therefore, your care plan should address a public health concern.
Planning nursing is nursing action plans to be implemented to address the problems within their nursing diagnosis has been determined with the aim of fulfilling the needs of the client. So public health nursing care plan is based on pre-defined nursing diagnoses and nursing plan drawn up should include the formulation of objectives, plans nursing actions to be performed and the criteria for assessing the results of the achievement of objectives.
The steps in the planning of public health nursing are as follows:
Identify alternative nursing actions.
Set techniques and procedures to be used.
Involve community participation in planning through village community consultation activities, or mini workshops.
Consider the community resources and facilities available.
Actions to be implemented must be able to meet the requirement, which was felt by the public.
Leads to the objectives to be achieved.
Action must be realistic.
Arranged sequentially.
***Follow example attached to this assignment!
You must utilize the attached form to complete the assignment. This assignment is an individual assignment and everyone must turn in one care plan before the end of class.
NURSING CARE PLAN
Student:
Date:
9/26/2021
Instructor
Course
NUR4200C
Patient Initial
AD
Unit/ Room#
DOB
07/01/2021
Code Status:
Full Code
Height/Weight
Allergies
No know
Temp (C/F Site)
Pulse (Site)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
Pain Scale 1-10
History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations
Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx)
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations
Contributing
Factors
Diagnostic
Label
Related to
As evidenced by
Signs and
Symptoms
Priority Nursing Diagnosis
(at least 2)
Written in three part statement
Planning
(outcome/goal)
Measureable goal during your shift
(at least 1 per Nursing diagnosis)
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal)
Rationale Each must be
supported with Evidence Based Citations
Evaluation
Goal Met, Partially Met,
or Not Met
& Explanation
MEDICATION LIST
Medications (with APA citations
Class/Purpose
Route
Frequency
Dose (& range)
If out of range, why?
Mechanism of action
Onset of action
Common side effects
Nursing considerations
specific to this patient
References
NURSING CARE PLAN RUBRIC
NAME: COURSE: DATE:
PATIENT INITIALS: PATIENT DISEASE/DISORDER:
Criteria
4 Exceeds Expectations
3 Meets Expectations
2 Approaching Expectations
1-0
Does Not Meet Expectations
Score
History of Present
Illness
HPI explained in detail with accurate and in- depth understanding of chief complaint and supported by evidence based citations
HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations
HPI explained in limited detail with marginal
understanding of chief complaint and no support from evidence based citations
HPI details limited with poor understanding of chief complaint and no evidence based citations to support
X2
Physical Assessment, & Diagnostic tests/ procedures
Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations
Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations
Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations
Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations
X2
Past Medical &
Surgical History, Pathophysiology
Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and
supported by evidence based citations
Past medical/surgical; history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations
Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations
No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence
X2
Erikson’s
Developmental Stages
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations
Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations
Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations
X2
Socioeconomic/ Psychosocial Assessment
Describes socioeconomic and cultural background in complete detail with references
Identifies 3 psychosocial concerns
Describes socioeconomic and cultural background in some detail with references
Identifies 2 psychosocial concerns
Describes socioeconomic and cultural background in vague detail without references
Identifies 1 psychosocial concern.
Describes socioeconomic and cultural background
with no detail without references
Identifies no psychosocial concerns
X1
Interprofessional
Consults & Discharge
Referrals
Lists 3 or more appropriate collaborative issues/concerns
Rationale demonstrates excellent understanding of consults and interventions
Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory
understanding of consults and
interventions
Lists 1 appropriate collaborative issue/concern
Rationale demonstrates vague understanding of consults and interventions
Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory
understanding of consults and
interventions
X2
Potential Health
Deviations
Identifies TWO prioritized risk factors in proper format
Writes 3 independent nursing interventions
Identifies 1 prioritized risk factor in proper format
Writes 2 independent nursing interventions
Identifies 2 prioritized risk factors but not in proper format
Writes 1 independent pertinent nursing intervention
Does not identify prioritized risk factors
Writes 0-1 independent nursing intervention not pertinent to the diagnosis
X3
Priority
Nursing Diagnosis
TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis
One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis
Written incorrectly with sufficient data to support diagnosis, not a priority
Written incorrectly, not in correct format, or without sufficient data to support diagnosis
X4
Planning/Goals &
Evaluation
Goal is measureable, realistic, related to the problem;
Data supports if goal is met, not met with appropriate revisions
Goal is not measureable, realistic, related to the problem;
Data somewhat supports if goal is met, not met with appropriate revisions
Goal is not measureable, not realistic, related to the problem;
Data vaguely supports if goal is met, not met with inappropriate revisions
Goal is not measureable, not realistic, not related to the problem;
Data does not support if goal is met, not met with inappropriate revisions
X2
Implementation and
Rationale
Identifies 4 independent interventions with teaching;
Each is supported with scientific rationale using textbook or evidence based citations
Identifies 3 independent interventions with teaching;
Scientific rationale is supported with scientific rationale using textbook or evidence based citations
Identifies 2 independent interventions with teaching;
Scientific rationale is vaguely relevant & not supported from textbook
Identifies 1 independent interventions with teaching;
Scientific rationale is not relevant & not supported from textbook
X2
Medications
Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug
Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug
Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug
Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient
X2
General Organization
Accurate APA format, Appropriate citations & references, No spelling or grammar errors
1-2 APA format errors, Some citations, references are appropriate, Minimal spelling or grammar errors
Many APA format errors, Inappropriate citations or references,
Many spelling or
grammar errors
No APA formatting, No citations or references included, Many spelling or grammar errors
X1
Total
/100 %
COMMENTS:
FACULTY SIGNATURE: DATE: