Social worker

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 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

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

Oxytocin

Carboprost (Methergine)

Hemabate

Misoprostol (Cytotec)

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)

Triponin I

PH

Myoglobin

PCO2

PO2

Cholesterol

BASE EX:

UA

SAT:

URINALYSIS

Range

Value

Value

Meaning

Findings

Meaning

Color

Gastroccult

Clarity

Hemoccult

Sp. Gravity

SEROLOGY

pH

HIV

Protein

GBS

Glucose

Gonorrhea/ Chlamydia

Ketones

Syphilis

Bilirubin

Hepatitis B

Occ. Blood

Rubella

Urobilogen

BLOOD TYPE

WBC

RH FACTOR

RBC

Epithelia

RADIOLOGY

WBC

EKG

RBC

CT

Epith Cell

PET SCAN

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

Input:

Output:

Cardiovascular Assessment:

Specialty devices:

Teaching needs:

Heart Sounds:

Circulatory Assessment:

Edema:

Pain assessment: (PQRST)- Specific area

Respiratory assessment

Special devices:

Teaching Needs:

Lung sounds:

Pulmonary assessment: (respiratory pattern)

Cough:

Respiratory treatment and rational for use:

Breast assessment:

Teaching Needs:

Breast Assessment:

Nipple assessment:

Breastfeeding plans:

Uterine Assessment:

Teaching needs:

Location:

Firmness:

GI Assessment:

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.)

Lochia Assessment:

Teaching needs:

Color:

Quantity:

Presence of clots:

Perineal Assessment:

Teaching needs:

REEDA:

Wound Care:

Thrombophlebitis Assessment:

Teaching needs:

Edema Assessment:

Teaching needs:

Emotional Assessment:

Teaching needs:

Edinburgh Postnatal

Depression Screening:

IV Therapies:

IV fluids infusing

IV Site 1: Assessment

Date of insertion: Change (site or dressing)

IV removal:

Reason for removal:

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/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 assist 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 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 patient that you are caring for. A list of planned actions that will assist 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.