Nursing Care Plan- Basic Conditioning Factors
Patient identifiers:
Age: Gender: Ht: Wt. Code Status:
Isolation: Development Stage (Erikson): Give the stage and rationale for your evaluation
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
Religious, 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:
ALLERGIES:
Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Get custom essay samples and course-specific study resources via course hero homework for you service – Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following:
1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication?
Medication Classification Dosage & Route Rationale Possible Negative Outcomes
CONCEPT MAP
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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
Lymph Amylase
Mono Lipase
Eosin Uric Acid
GBC indices Protein
MCV Albumin
MCH Cl
MCHC Enzymes
COAGs LDH
PT CPK
INR SGOT
PTT SGPT
ABGs (V or A) Troponin I
PH Myoglobin
PCO2
PO2 Cholesterol
BASE EX:
SAT:
URINALYSIS
Range
Value
Value
Meaning Others not listed:
Findings
Meaning
Color Gastroccult
Clarity Hemoccult
Sp. Gravity
pH EKG
Protein
Glucose CT Scan
Ketones
Bilirubin
Occ. Blood MRI or MRA
Urobilinogen
WBC
RBC
Epithelia Ultrasound
WBC
RBC
Epith Cell
Bacteria
Hyaline Cast
Gran Cast Bedside Procedures:
Leukocytes
Nitrite
ACCUCHECKS
Additional information:
Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment findings)
Vital Signs Time: Time:
Oxygenation/ Circulation Intake:
SpO2
1. 2. 3. Accu-check
1. 2. 3. 4. Output:
Cardiovascular Assessment
Specialty devices:
Teaching needs: Heart Sounds:
Skin Temp/Moisture/Color:
Edema: JVD:
Peripheral Pulses:
Pain assessment (OPQRST)
Rating:
Location:
Respiratory Assessment
Special devices:
Oxygen:
Teaching Needs:
Lung sounds:
Anterior:
Posterior:
Respiratory effort: Respiratory pattern: Reg/Irreg Cough:
Respiratory treatment:
Medication(s):
Frequency:
Rationale for use:
Neurological Assessment:
Assistive devices:
Teaching Needs: Level of Consciousness: Alert / Verbal / Pain / Unresponsive
Orientation: Person / Place / Time / Events
Fine motor function:
Gross motor functioning:
Sleep patterns (During admission):
Sleep patterns (at home):
GI Assessment:
LBM (include description):
Teaching needs: Abdominal Assessment: (observe – auscultate – palpate)
Alteration in eating or elimination patterns:
Nutrition Metabolic Assessment:
% diet taken:
Alternative nutritional methods:
GU assessment:
Teaching needs: Last void:
Due to void:
Alternative urinary elimination method: (if urinary catheter in place, 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 Therapy
IV fluids infusing:
Rate:
Tubing dated?
IV Site Assessment: Location
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 THE SPECIFIC RESPONSE.
PLAN OF CARE: Use your top “2” priorities
NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
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 client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)
Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch) Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?
NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
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 client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)
Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)
Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?
See the scenario attached and complete the care plan form template as much as possible.
SCENARIO
Develop a care plan for this patient.
You are the nurse caring for an older adult, 85 years old, complaining of shortness of breath without any activity. The resident stated, “help, I cannot breathe.” She has no history of any allergies. She is a widow and practices the catholic faith. She has an advance directive do not resuscitate. Medical records indicated patient has diagnoses for chronic failure with hypoxia, peripheral vascular disease, atrial fibrillation, chronic obstructive pulmonary disease, essential hypertension, chronic kidney disease stage 3, gastro-esophageal reflux disease without esophagitis, anemia, hypomagnesemia, type 2 diabetes mellitus without complication, heart failure, pure hypercholesterolemia, abdominal aortic aneurysm with rupture.
On the day of admission, her vital signs are as follows. Alert and oriented times 2, edema plus + 2 skin integrity extremities are cold.
Bp 166/100, HR 105, R 22 Temp 96.7*, Spo2 88 %, pain level 6/10
Weight 184lbs height 68 inches BMI 26.6. Mobility: short distance with rollator walker.
Home medications
Acetaminophen oral cap 325mg tab po q 4 hours for pain.
Diltiazem hcl er extended-release 240mg.
Fish oil 1000mg cap po q daily
Furosemide 20mg tab po q daily
Losartan potassium 50mg po q daily
Magnesium oxide 250mg Tb po q daily
Metformin 1000mg tab po q bid AM and EVENING.
Metoprolol succinate 50mg tab po q daily
Omeprazole 20mg po q daily
Potassium chloride 20meq tab po q daily
Simvastatin oral 40mg tab po daily at bedtime
