I hope this will help you.

For your Paper: Diagnosis

Signs & Symptoms
Your patients Signs and Symptoms
Pathology
Lab values related to diagnose and then what were your patients lab values (did they correlate?)
Medications AND why these specific meds?
Care Plan

Below are a couple examples of Nursing Care Plans. You may want to check the sites I have provided you as well.
No cutting and pasting. Work must be yours.

Remember when prioritizing client needs:

The ABC's are 1st and, don’t forget Maslow's Hierarchy of Human Needs.
Physiological needs always come first: Breathing, Bleeding, Water, Food, Sleep, Excretion, Think of what is necessary for survival.
Everything else comes after that.

The development of a nursing care plan steps developed from the nursing process which includes:
1. Assessment - collection of patient data
2. Determining the Nursing Diagnosis with identification of nursing diagnoses, goals and outcomes
3. Planning – Actually putting together and writing the care plan (include interventions)
4. Implementation - putting the Care plan into action
5. Evaluation – How will you evaluate it and ensure it is periodically updated
Try the following websites: http://www1.us.elsevierhealth.com/Ev...uctor/A-B.html
http://www.rncentral.com/nursing-library/careplans/bec
http://www.childbirths.com/euniversity/sample%20care%20plan.htm
The following links to case scenarios show you, in steps, how to develop a nursing care plan using NANDA languages. They are learning activities
for the nurses working for a facility owned by the University of Michigan. In these scenarios the nurses are directed to choose nursing diagnoses,
NOC outcomes and NIC interventions (this is all terminology that NANDA uses). Unfortunately, no answers are provided. However, you can see
how the process is supposed to flow from one step to the next and some of the critical thinking that goes into the making of the care plan.
http://www.med.umich.edu/nursing/snl/cs2.pdf - this is a adult surgical care planning case study activity
http://www.med.umich.edu/nursing/snl/cs3.pdf - this is an adult ICU care planning case study activity
http://www.med.umich.edu/nursing/snl/cs4.pdf - this is a pediatric care planning case study activity
http://www.med.umich.edu/nursing/snl/cs5.pdf - this is a pediatric ICU care planning case study activity
http://www.med.umich.edu/nursing/snl/cs6.pdf - this is a prenatal care planning case study activity
http://www.med.umich.edu/nursing/snl/cs7.pdf - this is a psychiatric care planning case study activity
http://www.med.umich.edu/nursing/snl/cs8.pdf - this is an ambulatory patient care planning case study activity
 Example Nursing Diagnosis and Careplan for N205 Mini careplans
Potential for Injury (Apsiration)
Assessment Data Related to Nursing Diagnosis Goal Nursing Interventions Evaluation
Nursing Diagnosis
What Objective and Subjective Potential for Injury (Aspiration) Goal (Should be broad statements which Interventions should be things that Evaluate based on the
Data lead you to this one diagnosis. related to dimminshed gag reflex solve the Problem part of the Nursing you do (either independently or patients progress
and impaired swallowing ability Diagnosis Statement. ) dependently) to assist the patient in towards each of the
Objective: reaching the goal. They should be outcome Criteria
Patient will not have injury related to focused on addressing the cause of
CVA with Left Sided Paralysis aspiration (10/20/95 2-10pm) the problem (the related to part of 1. Patient did not
the nursing diagnosis statement) have problems
Diminished Gag Reflex Outcome Criteria with choking
Place patient on side or with HOB to during my shift.
Specific and observable things which avoid aspiration of mucous. 2. Patient color was
Difficulty Swallowing Liquids pink.
allow an observer to determine if the
patient met the goal Feed patient liquids which have been 3. Patient lung
thickened, as thin liquids are more sounds remained
likely to cause aspiration. clear.
4. You may or may
1. Patient will have no choking not have lab/X-ray
episodes while eating. Monitor lung sounds for signs of
aspiration data to report,
2. Patient color will remain cyanotic depending on the
Subjective (from patient or family) 3. Patient lung sounds will remain day and what tests
clear Monitor Lab and X-ray data for have been
" Mom chokes every time she signs of aspiration. ordered.
eats". 4. Patient CXR will show no signs of
aspiration Goal Met, Continue
Plan.
ALSO INCLUDE
Was this an appropriate
Nursing Dx for THIS
PATIENT? It may turn
out that after you care
for the patient, you
discover a higher
priority nursing
diagnosis.

Assessment Data
(List the things your patient Fluid volume excess RT water retention Outcome Criteria:
has which make you suspect secondary to decreased renal perfusion
he/she is overhydrated)
Objective:
Weight gain in past month
Edema
Tight, shinny skin
Crackles in lungs
Decreased urine output
Na level 134
Hct level below 35
Subjective:
"My feet and legs are so
swollen"
"I just can't breath if I'm flat
in bed"
Sample Nursing Careplan for N205 : Fluid Volume Excess
Goal: Patient will not have
Nursing Diagnosis Interventions Evaluation
fluid volume excess
Restrict fluids to 350 cc per shift. 1. Clients weight
SR: Excessive fluids will worsen client's was stable at 145
and cardiac output 1. Client's weight will be condition. (Sparks, 110) lbs.
WNL for Ideal Body 2. Client stated she
Weight (give numbers). Weigh client at same time each day, using same could breathe
2. Client will verbalize scale. SR: Provides baseline and continuing better
ability to breathe database for monitoring changes and evaluating 3. Lungs had
comfortably. interventions. decreased
3. Lungs will be clear (Brunner, 1039) crackles
4. Vital Signs will Be WNL 4. Vital signs were T
5. Relevant lab values Administer diuretics (Lasix) as prescribed. SR: 98.6 P 87 R 24
(Sodium, Hct) will be To increase excretion of water. (Ulrich, 508) B/P 134/86
WNL ( Na 135-145) etc. Help client into a position that aids breathing, 5. Na was 135
6. Urine will be clear such as Fowler's or Semi-Fowler's. 6. Hct was 36
yellow with output SR: To increase chest expansion and improve 7. Urine was clear
>30cc/hr ventilation. (Sparks, 110) yellow with
7. Intake will not be greater output over 30
than output Encourage client to cough and deep breathe q2h. cc/hr
SR: To prevent pulmonary complications. 8. Intake was 350 cc
8. No evidence of skin (Sparks, 110) this shift with
breakdown. output of 475 =
Asculatate Lung Sounds q 4 hours. Monitor Pulse Negative fluid
Ox Q 4 hours, Monitor CXR results, as balance of 125 cc
performed. this shift.
SR: To look for pulmonary vascular congestion, 9. There was no skin
pleural peffusion, or pleural edema. (Ulrich, 508) breakdown
Assess vital signs q4h.
Assess lab values q shift.
Monitor extremities for venous return (check
pulses and capillary refill) q shift.
SR: Decrease in venous blood flow results in an
increase in venous pressure, a rise in capillary
hydrostatic pressure, a net filtration of fluid out
of the capillaries, and thus edema. (Brunner,625)
Administer vasodilators, as ordered. SR: To
improve renal blood flow. (Reduced renal
 perfusion stimulates the renin-angiotensin-
aldosterone mechanism) (Ulrich, 508)
Encourage client to restrict Na intake.
SR: Restriction of NA intake reduces the
amount of Na that
passes through the kidney and is reabsorbed. This
results in decreased retention of water. (Ulrich,
37)

Test urine specific gravity q8h.

SR: High specific gravity indicates fluid
retention. Fluid overload may alter electrolyte
values. (Sparks, 110)
Examine skin q8h for signs of bruising or other
discoloration.
SR: Edema may cause decreased tissue perfusion
with skin changes. (Sparks, 108)

Skin care q4h. (Cleanse wound with saline, dry,

apply polysporin and dry gauze dressing.)
SR: To prevent further skin breakdown. (Sparks,
108)

Reposition client q2h.

References

Brunner, L.S. & Suddarth, D.S. (1988). Medical-surgical nursing. Philadelphia: Lippincott.
Sparks, S.M. (1993). Nursing diagnosis reference manual (2nd ed.). Springhouse, PA: Springhouse Corporation.
Ulrich, S.P., Canale, S.W., & Wendell, S.A. (1994). Medical- surgical nursing care planning guides (3rd ed.). Philadelphia:
Saunders.