Nursing diagnosis in pe format

Nursing Care Plan Form

Student Name

Date

Patient (initials only)

Patient Medical Diagnosis

Nursing Diagnosis (use PES/PE format)

Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.)

Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

Rationale
(Provide reason why intervention is indicated / therapeutic; provide references.)

Outcome Evaluation & Re-planning

(Was goal met? How would you revise the plan of care according the patient’s response to current plan?)

1.

2.

3.

Statement #1

Statement #2

1.

2.

3.

1.

2.

3.

1.

2.

3.

1.

2.

3.

Outcome #1

Outcome #2

EVALUATION CRITERIA FOR NURSING CARE PLANS (NCP)

At least one nursing care plan (or update of care plan) will be evaluated per week on a pass-fail basis –

fails will be required to revise until final care plan is adequate

DAY 1 CARE PLAN IS A DRAFT – FACULTY TO REVIEW FOR SUGGESTIONS TOWARD FINAL PRODUCT – PASS-FAIL EVALUATION WILL BE ON DAY 2 CARE PLAN

Patient Profile Database Form (30%)

______Assessment: All subjective and objective data are documented on form (10%)

______Pathophysiology: Should be based on the medical diagnosis (10%)

______Laboratory Data: Noted as normal or abnormal and reason abnormal (10%)

Medication Preparation Log (10%)

______ Medications:

Nursing Care Plan Forms (60%)

______Nursing Diagnosis Statements: (15% points possible-see breakdown below)

_____Three statements are written (1 %/statement for a total of 3 possible points)

_____Only NANDA-approved nursing diagnoses are used (1 %/statement for

a total of 3 % possible)

_____ Statements are written in PES (for actual diagnoses) or PE (for potential or “at risk”

diagnoses) format (1%/statement for a total of 3% possible)

_____Diagnosis is supported by assessment data (1%/statement for a total of 3% possible)

_____ Nursing diagnoses are listed from highest to lowest priority. Life threatening

diagnoses (e.g. ABCs, infection, etc.) come first, then safety, then all others.

Usually existing problems come before “risk for" problems (1%/ statement for a

total of 3% possible)

______Plan: Goals and Outcomes Statements: (12 % possible-see breakdown below)

_____Two statements are required for each nursing diagnosis statement (2 %/ statement for a total of 6% possible)

_____Statements are prioritized (1%/set of goals for a total of 3% possible)

_____Statements are written in SMART format (1 %/ statement for a total of 3% possible)

______ Nursing Interventions with Rationale: (24 % possible-see breakdown below)

_____ Each goal has two interventions (1%/goal for a total of 8% possible)

_____ Each intervention has a rationale with a reference (1%/goal for a total of 8% possible)

_____ Statements are specific (what, when, how much, how often) (1% per goal for total of 8% possible)

______Evaluation: (9 %)

State if goal has been met; if not met or partially met, discuss whether will continue or modify plan (9%)

Final Grade: ___________ Date:____________ Instructor signature: __________________________

Evaluation minimum 85% required for a rating of ‘pass’, if not, student must rewrite care plan by end of clinical rotation. After that, it may consider as “fail”.