Nursing Care Plan: Basic Conditioning Factors
A. Patient identifiers:
Age: Gender: Ht: Wt. Code Status:
Isolation:
Development Stage (Erikson): Give the stage and rationale for your Assessment
Health Status
Date of admission:
Activity level: Diet:
Fall risk (indicate reason)
Client’s description of health status
Allergies: (include type of reaction)
Reason for admission:
Past medical history that relates to admission:
Socio-cultural Orientation
Cultural and Ethnic Background with current practices:
Socialization:
Family system: (Support system)
Spiritual:
Occupation: (across the lifespan)
Patterns of living: (define past and current)
Barriers to independent living:
Healthcare systems elements (continued) ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.
DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?
Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference
Potassium chloride 40 mEq PO
Ondansetron 4-8 mg slow ush IV q6 hr
Sultamethoxasole/trimethoprim 160/180
Dextrose 5% NS with 20 mEq KCL
CON CEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Hypovolemia
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
Nursing Diagnosis
Problem statement: (NANDA)
Related to: (What is happening in the body to cause the issue?)
Manifested by: (Specific symptoms)
.
LAB VALUES AND INTERPRETETION
LAB
Range
Value
Value
MEANING (If WDL then explain the possible reason for the lab)
LAB
Range
Value
Value
MEANING
HEMATOLOGY
CHEMISTRY
CBC
Glucose
WBC
BUN
RBC
Cr
HGB
GFR
HCT
Na
PLATLETS
K
Diff:
CO2
Polys
Ca
Bands
Phos
Lymphs
Amlylase
Mono’s
Lipase
Eosin
Uric Acid
GBC indices
Protein
MCV
Albumin
MCH
Cl
MCHC
Enzymes
COAG’S
LDH
PT
CPK
INR
SGOT
PTT
SGPT
ABG’S(V 0R A)
Troponin I
PH
Myoglobin
PCO2
PO2
Cholesterol
HCO3
UA
BASE EX:
Urine osmolality
URINALYSIS
Range
Value
Value
Meaning
Findings
Meaning
Color
Gastroccult
Clarity
Hemoccult
Sp. Gravity
pH
Protein
Glucose
Ketones
Bilirubin
Occ. Blood
RADIOLOGY
Urobilogen
Xray
WBC
EKG
RBC
Epithelia
PET SCAN
WBC
RBC
CT
Epith Cell
Bacteria
MRI
Hyal Cast
MRA
Gran Cast
Ultrasounds
Leukocytes
Nitrite
ACCUCHECKS
Endoscopy
Colonoscopy
Additional information:
Universal Self-Care Deficits: Assessment: (Highlight all abnormal assessment findings)
Vital Signs
Admission
Reassess
Oxygenation/ Circulation
Input:
SPO2
1. 2. 3.
Accu-check
1. 2. 3. 4.
Output:
Cardiovascular Assessment:
Specialty devices:
Teaching needs:
Heart Sounds:
Circulatory Assessment:
Edema: JVD:
Pain assessment: (PQRST)- Specific area
Respiratory assessment
Special devices:
Teaching Needs:
Lung sounds:
Pulmonary assessment: (respiratory pattern)
Cough:
Respiratory treatment and rational for use:
Neurological assessment:
Helpive devices:
Teaching Needs:
Neuro assessment: Level of Consciousness
Fine motor function:
Gross motor functioning:
Sleep patterns: (During admission)
GI Assessment:
LBM: (description)
Teaching needs:
GI assessment: (observe – auscultate – palpate)
Alteration in eating or elimination patterns:
Nutrition Metabolic Assessment:
% of diet taken:
Alternative nutritional methods:
GU assessment:
Teaching needs:
Last void:
Due to void:
Alternative urinary elimination method: (if Foley when inserted)
Bladder scan
Assessment of urinary patterns:
Urine assessment (color odor concentration etc.)
LMP
Integumentary Assessment:
Teaching needs:
Color/ Mucous membranes
Hydration:
Wound Care:
Condition of skin:
Nutritional Assessment
Teaching needs:
Diet:
Eating patterns:
Insulin administration:
Treatment of hypoglycemia:
Alternative feeding patterns:
IV Therapies:
IV fluids infusing
IV Site 1: Assessment
Date of insertion: Change (site or dressing)
IV removal:
Reason for removal:
Additional information:
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HIS RESPONSE.
PLAN OF CARE: Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal Assessment
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal : Create a SMART goal that relates to hospital stay/shift/day.
Long term goal : Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will Help the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
1.
2.
3.
Interventions for longterm goal:
1.
2.
3.
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
1.
2.
3.
Reassess for long-term goal:
1.
2.
3.
Was it met or not met there is no partially met.
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal Assessment
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom?)
Manifested by: (specific symptoms)
Short term goal: Create a SMART goal that relates to hospital stay.
Long term goal: Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will Help the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Was it met or not met there is no partially met.
Pilot Summer 2016 KC 9
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Basic Conditioning Factors in Nursing Care
A. Identifiers for patients:
Gender: Height: Weight: Code Status:
Isolation:
Development Stage (Erikson): Describe the stage and rationale for your assessment.
Condition of Health
Date of admission:
Activity level: Diet:
Fall risk (indicate reason)
Client’s description of health status
Allergies: (include type of reaction)
Reason for admission:
Past medical history that relates to admission:
Socio-cultural Orientation
Cultural and Ethnic Background with current practices:
Socialization:
Family system: (Support system)
Spiritual:
Occupation: (across the lifespan)
Patterns of living: (define past and current)
Barriers to independent living:
Healthcare systems elements (continued) ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.
DEFINE
