NURSING CARE PLAN

Student: __________________________ Date: _________________ Client Initials: ____________ Room #: ________ Age: _______ Male: _____ Female: ____ Race: ___________ Marital Status: __________ Occupation: __________________ Religious Preference: ____________ Allergies: ____________________________ Code Status: __________ Admission Date: ___________ Primary Medical Diagnosis and Related Surgical Procedure:

Secondary Diagnosis:

Knowledge of Key Medical/Surgical Diagnosis from above (SOURCE: ________________) Define the disease What causes this disease Explain how the normal physiological processes are altered by this disease Describe textbook signs and symptoms of the diagnosis and compare your patients presenting signs and symptoms with those found in the text For surgical diagnosis, include the surgical pathophysiology (what will be different after surgery).

Medical History: Injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, allergies, family history, social habits (alcohol, drugs smoking), socio-cultural history.

General InformationWill be found on Doctors admission orders. Check for newer orders to be sure that they are still current. Significance to Client Type of Order Clients Order Why is this being ordered?

Diet I/O Free Void/Urinal/Bedpan Bedside Commode/Foley

Activity Level

Restraints Accucheck Type of Insulin

Oxygen (amount and device)

Treatment Procedures

LABORATORY VALUES: ABNORMALS ONLY CLIENT RESULTS CBC RBC count Hgb Hct WBC count Neutrophils Lymphs Monos Eos PLATELET ACTIVITY Bleeding Time COAGULATION PTT PT INR D-Dimer CHEMISTRY Sodium (Na) Potassium (K) Chloride (Cl) Alk phos Total protein Calcium (Ca) Carbon Dioxide (CO2) Glucose Albumin INTERPRETATION/ANALYSIS What is this telling you about your patient?

TEST

DATE

NORMS

LABORATORY VALUES: ABNORMALS ONLY CLIENT TEST DATE NORMS RESULTS CARDIAC FUNCTION Troponin Myoglobin CK CPK CK-MB BNP SGOT LDH LIPID PROFILE Cholesterol Triglycerides HDL LDL

INTERPRETATION/ANALYSIS

PULMONARY FUNCTION ACE Anion Gap Lactic Acid/Lactate ARTERIAL BLOOD GAS pH PCO2 HCO3 PO2 SAO2 HEPATIC, BILIARY, PANCREATIC, & SPLENIC FUNCTION ALT ALP Ammonia Amylase AST Bilirubin
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LABORATORY VALUES: ABNORMALS ONLY TEST LDH Lipase A : G Ratio RENAL/URINARY FUNCTION Creatinine BUN MUSCULOSKELETAL FUNCTION ANA ESR (WSED) RA Factor Uric Acid URINALYSIS Color Specific Gravity pH Protein Bilirubin Glucose Ketones RBCs WBC/s Bacteria MICROBIOLOGY Source: DATE NORMS CLIENT RESULTS INTERPRETATION/ANALYSIS

HEPATIC, BILIARY, PANCREATIC, & SPLENIC FUNCTION (Contd)

DIAGNOSTIC TESTS TEST X-RAYS DATE CLIENTS RESULTS INTERPRETATION/ANALYSIS

CT Scans

MRI

Nuclear Medicine Studies

Ultrasound

ADDITIONAL INFORMATION:

PHYSICAL ASSESSMENT
HEALTH PATTERNS VITAL SIGNS: ___________________________________________ MENTAL STATUS/NEUROLOGICAL: Mood: calm_____ Sad_____ Angry_____ Anxious_____ Fearful_____ content:_____________________________________________________ Speech: smooth ___________ slurred____________ absent ____________ Inference: Alert _____ Drowsy _____ Lethargic _____ Comatose LOC: Glasgow coma scale score _________________________________ Opens eyes: 4-spontaneous, 3-to speech, 2-to pain, 1-no response Verbal: 5-orient x 3, 4-confused conversation, 3-inappropriate, 2-incomprehensible sound, 1-none Motor response: 6-obeys commands, 5-localized pain, 4-withdraws, 3-decorticate, 2-decerebrate, 1-none Pain: no_____ yes _____ Location _______________________________ intensity (0-10) _______________quality _______duration____________ HEAD/NECK: Sclera (color)__________ Conjunctiva __________Lips/Mucosa_________ PERRLA yes___ no___ explain___________________________________ Teeth: intact ____ missing____caries_____dentulous_____dentures______ Gross acuity: vision_______________ hearing _______________________ RESPIRATORY: Cough no___ yes___ frequency __________ productivity ______________ Breath sounds (clear or adventitious): anterior ____________________posterior _________________________ Symmetry:____________________________________________________ CARDIOVASCULAR/CIRCULATORY: Apical pulse: location _________rate ________ rhythm ________________ Peripheral pulses: volume/amplitude: 1+ weak, 2+ strong (normal), 3+ bounding Radial: rt. _____ lt. _____ DP/PT :rt. _______ lt.__________ Tissue perfusion: nailbed color ____________ temperature _____________ sensation _________ abnormalities __________ capillary refill: <3 sec. _____________ >3 sec. _____________ Peripheral edema: no_______ yes_______ abnormalities __________________________________________________ pitting (1+, 2+, 3+, 4+) _________________________________________ GASTROIINTESTINAL: Abdominal contour ____________________bowel sounds ______________ Abdomen: soft ______ firm _____and tender ______ /non-tender _______ OTHER DATA: Ht. ___________ Wt. ____________ % meal eaten __________________ Date of last BM _________________________ GENITOURINARY: Urine: color ___________ clarity ____________ odor _______________ Suprapubic area ___________ voids __________Foley catheter _______ OTHER DATA: Intake ____________________ Output _______________________ MUSCULOSKELETAL: Activity level__________________________________________________ Posture _____________________ gait __________ balance _____________ grip: strength ________________ equality ___________________________ ROM: full ________ limited _______and active _______ passive ___________ Explain _____________________________________________________ IINTEGUMENT: Color ____________ Uniformity ___________ Texture ______________ Turgor ___________ Moisture_____________ Temperature __________ Disruptions _________________________________________________ _____________________________________________________________ _____________________________________________________________ DATA CLUSTER_____________ List abnormal finding here

SIGNIFICANT/ACTUAL ASSESSMENT DATA Cluster data here Hygiene

NURSING DIAGNOSIS r/t and a/e/b

PRIORITY

Pain/Discomfort

Activity/Rest

Food/Fluid

Elimination

Safety

Neurosensory

Circulation

Respiratory

Teaching/Learning

Social Interaction

Sexuality

Ego Integrity

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CLIENT CARE PLAN - priority # NURSING INTERVENTION ASSESSMENT

Significant Client Data Nursing Diagnosis NANDA:

PLANNING
Goals Client Outcome SHORT TERM:

To be kept within the nursing scope of practicelist all the things that you will do to help resolve this problem

RATIONALE FOR INTERVENTIONS

Why are you doing the intervention?

EVALUATION
Was your goal met or not met. If goal is not met, reevaluate your interventions?

Etiology(R/T):

Signs & Symptoms (AEB) SUBJECTIVE:

LONG TERM:

OBJECTIVE:

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Reflective Clinical Journalrefer to page 3 in Syllabus.

Identify one or two objectives that you met in clinical today and tell your instructor exactly what you did to meet the objective. All objectives should be met by the end of your clinical experience. 1. Professional provider of care

2. Professional Member within the Discipline

3. Professional Manager of care

4. Two objectives for next clinical week

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