First things first..did you get the rubric that was posted on WebVista?? That is a good place to start..I went to the workshop.Almost didnt go, but decided to at last min and it made a difference. Also keep in mind that these posts are very helpful, but also that different school have different ways of doing care plans
. This is what I got out of the workshop:
the example she used was for Fluid volume deficit r/t diarrhea secondary to C.difficile
outcome(must be complete, measurable and time specific): Re-establish fluid balance within 48 hours.
Assessments(4 complete assessments):
1. assess skin turgor
2. check urine output
4.check lab data(BUN, creatinine, electrolytes)
Interventions(3 appropriate for nursing Dx)
1.Encourage 1oz.every hour po clear fluids
2.Administer anti-diarrheal meds as ordered by Dr.
3.Maintain strict I & O q8hr
the documentation(Data, Action, Response-use imagination, but be realistic)
be sure to date/time, use past tense(remember, we are documenting "at end of shift")
Data- (remember data is what we found on our assessment, so let assessment be your guide)refused po fluids .Diarrhea(liquid, brown, large amount)x4.Oral mucosa dry.skin turgor poor.vital signs(make something up). Foley drained 200mL concentrated urine.
Action(what we did about what we found- interventions)- provided 1oz po clear fluids q1hr. Administered lomodal at 0800 and 1200 as ordered by Dr.
Response(did it work? she said use imagination, but cannot be unrealistic)
Skin turgor____. Urine output____mL. etc...
be sure to sign name , NCC SN