DA Form 3888-2 Medical Record - Nursing Care Plan

DA Form 3888-2 - also known as the "Medical Record - Nursing Care Plan" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 3888-2 - was last revised on June 1, 1991. Download an up-to-date fillable PDF version of the DA 3888-2 below or request a copy through the chain of command.

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MEDICAL RECORD - NURSING CARE PLAN
For use of this form, see AR 40-66; the proponent agency is the OTSG
INSTRUCTIONS: Number and initial each recording.
1. Date
2. RN
6. Date Accom-
Identified
Initials
3. #
4. Problems
5. Expected Outcomes (Goals)
plished Revised
(Continue on Reverse.)
5. Discharge Considerations.
6. Patient Identification.
(For typed or written entries give: Name - last, first, middle;
grade; date; hospital or medical facility)
DA FORM 3888-2, JUN 1991
REPLACES DA FORM 3888-4 (TEST), AUG 85 WHICH IS OBSOLETE
APD LC v1.01
MEDICAL RECORD - NURSING CARE PLAN
For use of this form, see AR 40-66; the proponent agency is the OTSG
INSTRUCTIONS: Number and initial each recording.
1. Date
2. RN
6. Date Accom-
Identified
Initials
3. #
4. Problems
5. Expected Outcomes (Goals)
plished Revised
(Continue on Reverse.)
5. Discharge Considerations.
6. Patient Identification.
(For typed or written entries give: Name - last, first, middle;
grade; date; hospital or medical facility)
DA FORM 3888-2, JUN 1991
REPLACES DA FORM 3888-4 (TEST), AUG 85 WHICH IS OBSOLETE
APD LC v1.01
MEDICAL RECORD - NURSING CARE PLAN (Continued)
INSTRUCTIONS: Number and initial each recording.
1. Date
2. RN
6. Date Accom-
Identified
Initials
3. #
4. Problems
5. Expected Outcomes (Goals)
plished Revised
NURSING DIAGNOSTIC CATEGORY GUIDELINES:
HEALTH PERCEPTION-MANAGEMENT PATTERN:
ACTIVITY-EXERCISE PATTERN:
Depression, Reactive (Situational)
Health Management, Deficit, Total
Activity Tolerance, Decreased (Specify Level)
Fear (Specify Focus)
Health Management Deficit (Specify)
Airway Clearance, Ineffective
Personal Identity Confusion
Infection, Potential for
Breathing Pattern, Ineffective
Self Esteem Disturbance
Physical Injury, Potential for
Cardiac Output, Alteration In: Decreased
Role-Relationship Pattern
Noncompliance (Specify)
Diversional Activity Deficit
Grieving, Anticipatory
Noncompliance, Potential (Specify)
Gas Exchange, Impaired
Grieving, Dysfunctional
Poisoning, Potential for
Home Maintenance Management
Independence-Dependence Conflict,
Suffocation, Potential for
(Mild, Moderate, Severe, Potential, Conflict)
Unresolved
Nutritional-Metabolic Pattern:
Joint Contractures, Potential
Parenting, Alteration in
Decubitus Ulcer
Mobility, Impaired Physical (Specify Level)
Parenting, Potential Alteration in
Fluid Volume Deficit Potential
Self-Care Deficit, Total (Specify Level)
Social Isolation
Fluid Volume Deficit, (Actual)(1)
Self-Bathing-Hygiene Deficit (Specify Level)
Socialization, Alterations in
Tissue Perfusion, Chronic Alteration in
Translocation Syndrome
Fluid Volume Deficit, (Actual)(2)
Nutrition, Alteration in: Potential for More
Cognitive-Perceptual Pattern:
Verbal Communication, Impaired
Than Body Requirements, or Potential
Cognitive Impairment, Potential
Violence, Potential for
Obesity; More Than Body Requirements,
Comfort, Alteration In: Pain
Sexuality-Reproductive Pattern:
or Exogenous Obesity; Less Than Body
Pain Self-Management Deficit
Rape Trauma Syndrome
Requirements, or Nutritional Deficit
Knowledge Deficit (Specify)
Rape Trauma Syndrome: Compound
Rape Trauma Syndrome: Silent Reaction
(Specify)
Sensory Deficit (Specify), Uncompensated
Skin Integrity, Potential Impairment of,
Sensory-Perceptual Alterations: Input
Sexual Dysfunction
or Potential Skin Breakdown
Excess or Sensory Overload
Coping-Stress Tolerance Pattern:
Skin Integrity, Impaired
Short-Term Memory Deficit, Uncompensated
Coping, Family: Potential for Growth
Elimination Pattern:
Thought Processes, Impaired
Coping, Ineffective Family: Disabling
Alteration in Bowel Elimination: Constipation
Sleep-Rest Pattern:
Coping, Ineffective Family: Compromised
or Intermittent Constipation Pattern
Sleep-Pattern Disturbance
Coping, Ineffective (Individual)
Alteration in Bowel Elimination: Diarrhea
Self-Perception-Self-Concept Pattern:
Value-Belief Pattern:
Alteration in Bowel Elimination: Incontinence
Anticipatory Anxiety (Mild, Moderate, Severe)
Spiritual Distress (Distress of Human Spirit)
or Bowel Incontinence
Anxiety, Mild
Urinary Elimination Pattern, Altered
Anxiety, Moderate
REFERENCE:
Urinary Elimination: Impairment of:
Anxiety, Severe (Panic)
Manual of Nursing; Diagnosis 1983
Incontinence
Body Image Disturbance
Marjory Gordon, McGraw Hill Pub. Co.
Urinary Elimination, Impairment of: Retention
Reprinted by permission of McGraw Hill
REVERSE OF DA FORM 3888-2, JUN 1991
APD LC v1.01

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