1
Brain TIA nursing care plan
Nurs 3263 Basic Concepts Practicum – Care Plan Evaluation Tool
Student Name: GIAU TA Date:
11/02/2016
TOTAL POINTS POINTS RECEIVED
CRITERIA
ASSESSMENT 10
Subjective Data 5
Objective Data 5
DEVELOPMENTAL TASK 5
Stage identified per Erikson 2.5
Comparison of client to Erikson's Developmental task 2.5
PATHOPHYSIOLOGY OVERVIEW5
NURSING DIAGNOSES 20
Pertinent diagnoses identified 5
Etiology 5
Manifestations 5
Prioritized Ranking 5
GOAL STATEMENTS
15
Derived from nursing diagnoses 5
Goal / Outcome criteria measurable 6
Time frame 4
INTERVENTIONS 30
Individualized / appropriated interventions 11
Rationale for interventions 11
One (1) teaching intervention per Nursing Diagnosis 5
Reference for interventions / rationales 3
EVALUATION 15
Documents client's response 6
Evaluates client's response in relation to outcome criteria 5
Overall statement in relation to goal 4
GRADE (NOTE: A grade of 75% or above is satisfactory) 100
FACULTY:
Data Tool Rev and updated Jan 2016 DJ/ML
, 2
PRAIRIE VIEW A&M UNIVERSITY
College of Nursing
BASIC CONCEPTS PRACTICUM – NURS 3263
DATA COLLECTION TOOL
Student’s Name Giau Ta Date 11/02/2016
Biographical data
Client’s initials NN Unit/Room No. 324 Age 90
Gender F Ethnicity Asian Religion Christian Marital Status Married
Occupation Retired Date of Admission 10/28/2016
Admitting Problem/Diagnosis Slurred speech Brain TIA
Chief Complaint (Why did the patient come to the hospital – in patient’s own words)
“While I was talking with my daughter in law, my speech was suddenly slurred and the right
side of my face drooped. My daughter in law knew there was something wrong happening to me
so she called an ambulance. ”
Past Health History
Asthma N/A Emphysema N/A Bronchitis N/A Pneumonia N/A TB N/A
Angina N/A MI N/A Anemia N/A Hypertension N/A Rheumatic Fever
N/A Pacemaker N/A Peripheral Vascular Disease N/A Blood Disorders N/A
Stroke X Skin Disease N/A Bladder Infections N/A Kidney Disease N/A
Ulcers N/A DM N/A Dental Problems N/A Fractures N/A Congenital
Heart Defects N/A
Surgeries N/A
Family Health History
Condition Family Members Condition Family Members
Heart Disease N/A Tuberculosis N/A
Hypertension N/A Asthma N/A
Stroke N/A Mental Illness N/A
Diabetes N/A Alcoholism N/A
Cancer N/A Kidney Disease N/A
Brain TIA nursing care plan
Nurs 3263 Basic Concepts Practicum – Care Plan Evaluation Tool
Student Name: GIAU TA Date:
11/02/2016
TOTAL POINTS POINTS RECEIVED
CRITERIA
ASSESSMENT 10
Subjective Data 5
Objective Data 5
DEVELOPMENTAL TASK 5
Stage identified per Erikson 2.5
Comparison of client to Erikson's Developmental task 2.5
PATHOPHYSIOLOGY OVERVIEW5
NURSING DIAGNOSES 20
Pertinent diagnoses identified 5
Etiology 5
Manifestations 5
Prioritized Ranking 5
GOAL STATEMENTS
15
Derived from nursing diagnoses 5
Goal / Outcome criteria measurable 6
Time frame 4
INTERVENTIONS 30
Individualized / appropriated interventions 11
Rationale for interventions 11
One (1) teaching intervention per Nursing Diagnosis 5
Reference for interventions / rationales 3
EVALUATION 15
Documents client's response 6
Evaluates client's response in relation to outcome criteria 5
Overall statement in relation to goal 4
GRADE (NOTE: A grade of 75% or above is satisfactory) 100
FACULTY:
Data Tool Rev and updated Jan 2016 DJ/ML
, 2
PRAIRIE VIEW A&M UNIVERSITY
College of Nursing
BASIC CONCEPTS PRACTICUM – NURS 3263
DATA COLLECTION TOOL
Student’s Name Giau Ta Date 11/02/2016
Biographical data
Client’s initials NN Unit/Room No. 324 Age 90
Gender F Ethnicity Asian Religion Christian Marital Status Married
Occupation Retired Date of Admission 10/28/2016
Admitting Problem/Diagnosis Slurred speech Brain TIA
Chief Complaint (Why did the patient come to the hospital – in patient’s own words)
“While I was talking with my daughter in law, my speech was suddenly slurred and the right
side of my face drooped. My daughter in law knew there was something wrong happening to me
so she called an ambulance. ”
Past Health History
Asthma N/A Emphysema N/A Bronchitis N/A Pneumonia N/A TB N/A
Angina N/A MI N/A Anemia N/A Hypertension N/A Rheumatic Fever
N/A Pacemaker N/A Peripheral Vascular Disease N/A Blood Disorders N/A
Stroke X Skin Disease N/A Bladder Infections N/A Kidney Disease N/A
Ulcers N/A DM N/A Dental Problems N/A Fractures N/A Congenital
Heart Defects N/A
Surgeries N/A
Family Health History
Condition Family Members Condition Family Members
Heart Disease N/A Tuberculosis N/A
Hypertension N/A Asthma N/A
Stroke N/A Mental Illness N/A
Diabetes N/A Alcoholism N/A
Cancer N/A Kidney Disease N/A
