NUR 2100 Gastrointestinal Obstruction Nursing Care Plan Worksheet

Reflect 1 nursing diagnosis as a priority and da second nursing diagnosis as a potential, followed by their perspective interventions.

Patient Information:

74 yo Female presented to the emergency room with acute abdominal pain with a palpable mass and constipation.

Pt hx Asthma and previous hernia surgery, also hypertensive.

Current medications: Metropolol

Diltiazem

LevofloxacinMost recent Vital signs: BP- 142/65  HR- 91  RR-19   Temp 96.8  O2-96  Pain 4/10

Pt was admitted and placed on an NG tube.

This is pretty much what I have please feel free to add more information in order to complete the care plan.

NUR2100 Clinical Assignment
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Student Name: ______________________________ Date ___________________
Care Plan #1 For a Medical-Surgical Client
Identify a patient you cared for in clinical. Use the information about selected patient to
complete the care plan.
Care Plan for:
Medical Diagnosis
Patient EMR
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NUR2100 Clinical Assignment
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Part 1: Nursing Process Model
Nursing Assessment
Subjective
Objective
Database
Nursing Diagnosis (Priority Nursing Diagnosis and 1 Potential Diagnosis) NANDA
Priority DX
Potential
Planning (SMART Goals)
Re: Priority
Re: Potential
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NUR2100 Clinical Assignment
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Implementation – A. Independent Nursing Actions (Teaching)
Activities
Diet and Nutrition
Prevention and
Rehabilitation
Implementation – B. Dependent Nursing Actions: Also state your Nursing Responsibilities
Medications and
Treatments
Include: Drug Classification, How
is the drug taken, What are the side
effects and adverse effects, what to
do with the side effects or prevent
them from happening
Diagnostic Procedures
Include: What are your
responsibilities as a Nurse,
before, during and after the
procedure
LAB Exams
Include: Why should be done,
Normal Levels, What does an
abnormal result indicate?
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NUR2100 Clinical Assignment
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Evaluation (Outcome of Activities):
Nursing Actions
Must include assessment, interventions, and patient teaching, accompanied by rationale for
doing each.
Action
Rationale
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NUR2100 Clinical Assignment
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Part 2: Clinical Judgement Model- Ref: Caputi (2019).
Recognize Cues- NOTICING
Signs and Symptoms
• Appearance
• Behavior
• Cognition
• Thought processes
Analyze Cues-INTERPRETING
• Clustering of information
• Recognizing inconsistencies
• Determining the importance of
information
• Distinguishing the relevant
from irrelevant information
• Judging how much ambiguity is
acceptable
• Comparing and contrasting
Prioritize Hypotheses
• Setting Priorities
Generate Solutions
• PLAN nursing interventions
➢ Per disease process
➢ Patient activities
➢ Diet and Nutrition
➢ Medication
➢ Therapeutic procedures
Take Action-RESPONDING
• Delegating
• Communicating
• Teaching
• Implementation
Evaluate Outcomes- REFLECTION
• Effectiveness of:
➢ Accuracy of diagnosis
➢ Interventions conducted
➢ Medication
➢ Procedures done
Reference page: Use the following page to write the reference list used in preparing this care
plan (APA style 7th ED.).
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NUR2100 Clinical Assignment
References
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NUR2100 Clinical Assignment
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CARE PLAN GRADING RUBRIC
CATEGORIES
COMMENTS
Patient Information
Medical Diagnosis
Patient EMR
Part 1: Nursing Process Model
Subjective Data (Minimum of 3)
Objective Data (Minimum of 3)
Nursing Diagnosis: NANDA, Related To, AEB
(Minimum of 2)
Goal: Condition, Time Frame, Parameters
(Minimum of 3)
Assessment, Interventions, Patient Teaching, and
Rationales for each (Minimum of 6)
Part 2: Clinical Judgement Model
Identify Client’s Needs (Minimum of 3)
Make Clinical Judgement (Minimum of 2)
Clinical Decisions (Minimum of 5)
Form a Hypothesis (Minimum of 1)
Generate Solutions (Minimum of 5)
Take Actions (Minimum of 5)
Evaluate Outcomes (Minimum of 2)
Reference Page
Cited all content used in the care plan
Citation followed the APA7th style formatting
Instructor’s Feedback
Reviewed with Student:
Faculty:
________________________________ (Student Signature)
________________________________ (Faculty Signature)
Date: ________________________________
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