Nursing care plan

1 This is intended as a guide and is subject to change as needed

Brief RAM Assessment/Data Collection Sheet (To accompany Care Plan Design Form) Student Name______________________ Clinical Site_________________ Date _____________ Client’s Initial Code: Code Status: Vital Signs: Time_____________

T_______ Route______ AP______ Radial______ R _______ O2 Sat______

Primary Diagnosis PMH PSH

Pain Assessment:

Admission Date: Ht.____ Wt._____

Allergies

RAM Behaviors—Physiologic Oxygenation (Vital signs above) Protection

O2____ L/M via__________ Lung Assessment: Cardiovascular Assessment:

Skin Status: Color Temperature Turgor

Wounds: Drains: Last Dressing Change: Type of Dressing

Nutrition Elimination Diet: Appetite:

TF Bolus/Gravity/Pump Type of feeding: Rate

Bowel N/V/D  Incontinent  Ostomy (type) Last BM: Description: Abdominal Assessment:

Urine  Incontinent Last Void: Urine Output:(Description): Bladder distention?  Catheter Type Size Date inserted:

Fluid and Electrolytes

IV(s): Site: Gauge_____ Rate___________ Assessment: HL/CVP/Other Access

Rest and Activity Endocrine Neurologic Function & Senses (Pain assessment above) Activity: OOB/ BRP/Bedrest Activity tolerance: ROM: Gait: Transfers: Sleep:

Glucometer Readings: Assessments of Endocrine Function:

Overall appearance: LOC: Mood & Affect Paralysis/Paresis

Review of cranial nerves: Senses: MMSE Score____ Glasgow Coma Score____

2 This is intended as a guide and is subject to change as needed

Psychosocial

Self Concept Role Function Interdependence Body Image/Religion /Erickson’s Stage

Roles/Role Transition

Support Systems

Stimuli Focal Conceptual Residual

Medications Medication Dose Frequency Route Nursing Considerations

Laboratory and Diagnostic Studies (CBC, UA, Chemistry, Drug levels, Cultures, X-Rays, CT, MRI, etc.)

Teaching and Discharge Needs Related to Behaviors and Stimuli

3 This is intended as a guide and is subject to change as needed

Student Name: ____________________________ Patient Initials CODE_____________ Instructor: _______________________________ Date______________________

Nursing Care Design Sheet

Behaviors Non-Observable Observable (Subjective) (Objective)

Stimuli Focal, Contextual, Residual

Nursing Diagnoses NANDA

List 3 in priority order. Check the one you address.

Nursing Interventions and Rationales

(Best Evidence-Based Rationales with references)

Evaluation of (Impact) Patient Goals/Outcomes

Patient Care Goals/Outcomes

Short and Long Term (Including timeframes)

Indicate the Mode __Physiologic Mode __Self Concept Mode __Role Function Mode __Interdependence

1. Student Name:
2. Clinical Site:
3. Date:
4. Clients Initial Code:
5. Code Status:
6. Vital Signs Time:
7. Primary Diagnosis:
8. PMH:
9. PSH:
10. T:
11. Route:
12. AP:
13. Radial:
14. R:
15. O2 Sat:
16. Pain Assessment:
17. undefined:
18. undefined_2:
19. Allergies:
20. Incontinent: Off
21. Ostomy type: Off
22. Incontinent_2: Off
23. IVs Site Gauge Rate Assessment HLCVPOther Access:
24. Bowel NVD Incontinent Ostomy type Last BM Description Abdominal Assessment:
25. Catheter: Off
26. Glucometer Readings Assessments of Endocrine Function:
27. MMSE Score:
28. Glasgow Coma Score:
29. Body ImageReligion Ericksons Stage:
30. RolesRole Transition:
31. Support Systems:
32. FocalRow1:
33. ConceptualRow1:
34. ResidualRow1:
35. MedicationRow1:
36. DoseRow1:
37. FrequencyRow1:
38. RouteRow1:
39. Nursing ConsiderationsRow1:
40. MedicationRow2:
41. DoseRow2:
42. FrequencyRow2:
43. RouteRow2:
44. Nursing ConsiderationsRow2:
45. MedicationRow3:
46. DoseRow3:
47. FrequencyRow3:
48. RouteRow3:
49. Nursing ConsiderationsRow3:
50. MedicationRow4:
51. DoseRow4:
52. FrequencyRow4:
53. RouteRow4:
54. Nursing ConsiderationsRow4:
55. MedicationRow5:
56. DoseRow5:
57. FrequencyRow5:
58. RouteRow5:
59. Nursing ConsiderationsRow5:
60. MedicationRow6:
61. DoseRow6:
62. FrequencyRow6:
63. RouteRow6:
64. Nursing ConsiderationsRow6:
65. MedicationRow7:
66. DoseRow7:
67. FrequencyRow7:
68. RouteRow7:
69. Nursing ConsiderationsRow7:
70. MedicationRow8:
71. DoseRow8:
72. FrequencyRow8:
73. RouteRow8:
74. Nursing ConsiderationsRow8:
75. MedicationRow9:
76. DoseRow9:
77. FrequencyRow9:
78. RouteRow9:
79. Nursing ConsiderationsRow9:
80. MedicationRow10:
81. DoseRow10:
82. FrequencyRow10:
83. RouteRow10:
84. Nursing ConsiderationsRow10:
85. MedicationRow11:
86. DoseRow11:
87. FrequencyRow11:
88. RouteRow11:
89. Nursing ConsiderationsRow11:
90. CBC UA Chemistry Drug levels Cultures XRays CT MRI etc:
91. Teaching and Discharge Needs Related to Behaviors and StimuliRow1:
92. Patient Initials CODE:
93. Instructor:
94. Date_2:
95. Behaviors NonObservable Observable Subjective ObjectiveRow1:
96. Behaviors NonObservable Observable Subjective ObjectiveRow1_2:
97. Stimuli Focal Contextual ResidualRow1:
98. Nursing Diagnoses NANDA List 3 in priority order Check the one you addressRow1:
99. Patient Care GoalsOutcomes Short and Long Term Including timeframesRow1:
100. Nursing Interventions and Rationales Best EvidenceBased Rationales with referencesRow1:
101. Evaluation of Impact Patient GoalsOutcomesRow1:
102. LM via:
1. 1:
2. 0:
1. 0:
2. 1:
103. Admission Date:
1. 0:
2. 1:
3. 2:
104. Skin Status Color Temperature Turgor:
1. 1:
2. 2:
3. 3:
4. 0:
1. 0:
2. 1:
1. 0:
2. 1:
3. 2:
4. 3:
105. Diet Appetite:
1. 0:
2. 1:
106. Group1:
1. 0: Off
2. 1: Off
3. 2: Off
107. Check Box3:
1. 0: Off
2. 1: Off
3. 2: Off
108. Text2:
1. 1:
2. 0:
1. 0:
2. 1:
1. 0:
1. 0:
2. 1:
2. 1:
1. 0:
2. 1:
1. 0:
2. 1:
3. 2:
4. 3:
109. Text4:
110. Text5:
1. 0:
2. 1:
111. Gauge:
1. 0:
2. 1:
112. Rate:
1. 1:
2. 0:
1. 0:
2. 1:
113. Check Box6:
1. 1: Off
2. 2: Yes
3. 0:
1. 0: Off
2. 1: Off
3. 2: Off
4. 3: Off
114. Text7:
115. Text9:
1. 0:
2. 1:
3. 2:
4. 3:
116. Text10:
1. 0:
2. 1:
117. Text11:
118. Check Box12:
1. 0: Off
2. 1: Off
3. 2: Off
4. 3: Off