NURSING care p;

CHCCareplanGenericRN-MEDSURGSTUDENTSSAMPLE1.doc

Home >Nursing homework help >NURSING care p;

CHC

Nursing Care Plan

STUDENT NAME:	DATE:	COURSE:
CLIENT INITIALS:	DATE OF ADMISSION:	AGE:	GENDER:
HT:	WT:	ALLERGIES:
CODE STATUS:
RACE/ETHNICITY:	CULTURAL CONSIDERATIONS:
RELIGION/SPIRITUAL CONSIDERATIONS:
OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES:
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc)
SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics)
I. ADMITTING MEDICAL DIAGNOSIS:
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
II. SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses such as DM, COPD, etc)
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
III. SECONDARY MEDICAL DIAGNOSIS:
Definition:
Etiology/pathophysiology:
Common signs/symptoms:
Potential complications:
IV. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)
V. PAST MEDICAL/SURGICAL HISTORY:
VI. SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed and explanation)
VII. COMPLICATIONS R/T TO ABOVE:
VIII. CONSULTS: (include date and reason for consult)
IX. DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test, and results)

X. LABS:

Lab Test	Purpose	Normal Values	Client Results	Interpretation of Abnormal Labs

XI. MEDS:

Medication (Brand and Generic Names)	Classification	Prescribed Dose, Freq, Route	Mechanism of Action	Patient Specific Indications	Side effects/Nursing Implications

XII. IV FLUIDS:	Solution	Rate	Tonicity
XIII. IV SITE(S):
XIV. PT/OT
XV. RESP TX:	Frequency	Type	Rationale
XVI. NURSING INTERVENTIONS: (frequency, type, description, and/or N/A)
VS:	date/time	temp /route	bp	p	r


Pain level:	0-10 scale	Location	PQRST
Neuro checks:
Cardiac monitor:	Pacemaker/ICD:	Hemodynamic monitoring:
Oxygenation:	Method of Delivery	Flow	Rate	Pulse Oximetry
Vent settings:	Mode	TV	FiO2	Rate	PEEP/CPAP
ABGs:	Suctioning:	Method	Frequency	Result
Nutrition: Weight:	Diet	Appetite	Tolerance	Wt gain/loss	Dentition	Chewing/ Swallowing
Enteral feeding:	Route	Indication	Formula	Rate	Tolerance
					Glucose (FS or lab)
Bowel/bladder elimination:	I&O:
Foley	NG	Ostomy	Drains	Other tubes
Dressing/wound care:	Location	Appearance
Mobility:
Ortho: (traction, cast, etc)	Activity/assistive aids:
Safety considerations:	Restraints: (date, type and justification)
Sleep/rest:	Hours	Quality	Aides

XVII. HEAD-TO-TOE ASSESSMENT:

Neuro:

HEENT:

Resp:

C/V:

GI:

GU:

Reproductive: (Maternal to include breasts, fundus, peritoneum, and lochia)

M/S:

Skin/hair/nails:

Psychosocial: (include affect)

XVIII. NURSING DIAGNOSES: (minimum of 5, prioritized)

XIX. NURSING CARE PLAN: Directions:

1. Formulate a NCP using (3) nursing diagnoses:

a. Two (2) are the priority nursing diagnoses from the above list.

b. The 3rd nursing diagnosis is always Knowledge Deficit.

c. Write full nursing diagnoses statements.

Example: Ineffective airway clearance R/T increased sputum production as evidenced by ineffective cough and coarse rhonchi.

Note: if nursing diagnosis is “Risk for” there is no evidence to report.

d. Include client’s level on Maslow’s Hierarchy.

2. Outcomes:

a. Include Nursing Outcome Classification (NOC).

b. State (2) STGs and (1) LTG.

c. Goals must be client-centered, specific, measurable, realistic, and have a time frame for achievement.

Examples: STG: Lungs will be clear in 8 hours. LTG: Client will demonstrate colostomy care by time of D/C.

Note: Sometimes it is more appropriate for LTGs to extend beyond D/C.

3. Interventions:

a. Include Nursing Intervention Classification (NIC).

b. Prioritize interventions in order of performance.

c. Must be individualized/specific/with frequencies/and be directly related to goals.

d. Cite work for all interventions

Example: 1. Observe/assess resp status for rate, depth, and chest wall movement Q4 hrs and PRN (Lemone & Burke, 2004)

4. Rationales: Specific to each intervention listed and scientific.

Example: 1. Tachypnea, shallow resp, and asymmetric chest movement may be indicative of resp compromise (Lemone & Burke, 2004).

Note: Use nursing textbooks and scholarly journals only.

No medical dictionaries or health-related internet web sites are to be used.

Cite work for all rationales.

Note: Last page of NCP must include APA formatted reference page for all works cited in interventions and rationales.

5. Documentation: Document your interventions as you would in written nurses’ notes. Example: 0800 RR shallow at 24/min, even, non-labored.

6. Evaluation: Evaluate each STG as met, partially met, or not met and care plan status as D/C, continue, or revise.

Example: Goal not met. Revise care plan. Note for teaching care plan: In order for learning to have taken place, the client must verbalize or demonstrate something.

Example: Verbalized how to read labels on canned goods for sodium content.

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

INTERVENTIONS

RATIONALES

DOCUMENTATION

EVALUATION

NOC:

NIC:

Maslow’s Hierarchy Level:

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

INTERVENTIONS

RATIONALES

DOCUMENTATION

EVALUATION

NOC:

NIC:

Maslow’s Hierarchy Level:

NURSING

DIAGNOSIS

STATEMENT

OUTCOMES

INTERVENTIONS

RATIONALES

DOCUMENTATION

EVALUATION

NOC:

NIC:

Maslow’s Hierarchy Level:

PBVI 9.12.12