Patinet : A-Zebby

Chamberlain College of Nursing

Nursing 324 - 325 Care plan Packet

Date of care:__________________________________ Client Initials:________ Sex:______ Age:______ Rm#________

Religion:________ Allergies:_________________________ Admission date:_____________ Code status___________

Admitting diagnosis _______________________________________________________________________________

Social Hx:________________________________________________________________________________________

PMH:___________________________________________________________________________________________

Recent Surgeries _________________________________________________________________________________

Chief Complaint __________________________________________________________________________________

Narrative Note/SBAR:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Psychosocial Assessment:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________​​​​​________________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSTIC TESTS

Test	Date	Result	Reason(s) Needed and if abnormal- why?
CXR
EKG
CT
Others

Prescriptions/Orders

Item	Reason (explain specifically why ordered for this patient)
Diet
I/O
VS
Activity
Accu-check
Foley
NG tube
PEG/PEJ tube
Chest tube
Trach
Suctioning
Drains
Ostomy
Dressing change &/or wound care
Treatments
Special Equipment
Other

Therapies	Activity/Tx	Reason(s) Needed
Resp.
PT
OT
Speech
Other

IV ACCESS

Type:
Site:	Fluid/rate:
Reason(s) for IV access:

Labs only as indicated	Result	Normal	Labs only as indicated	Result	Normal
NA			135-145mEq/L	Albumin			3.5-5gm/dl
K			3.5-5.0mEq/L	Total Protein			6.4-8.3 gm/dl
Cl			98-106mEq/L	Hgb			12-18m/dl
CO2				Hct			37-52m/dl
Calcium			9-10.5mg/dl	Platelets			150-400 M/mm3
Mag			1.3-2.1mEq/L	PT			11-12.5 sec
Phos				PTT			30-40 sec
BUN				D. Bilirubin			0.1-0.3 mg/dl				55-70%
Creatinine				T. Bilirubin			0.3-1 mg/dl
				WBC
Glucose			80-100mg/dl	Lymphocytes			20-40%
Alk. Phos.			3-120 units/l	Monocytes			2-8%
ALT AST			4-36 units/L 0-35 units/dl	Eosinophils			1-4%
Amylase			60-120 units/dl	Basophils			0.5-1%
Lipase			0-160 units/L	MCV			80-95 m3
CPK			30-170 units/L	MCHC			32-36 gm/dl
Troponin			<0.03 ng/mL	MHC			27-31 pg
BNP			<100 pg/mL	MPV			7.4-10.4 fL
LDH			100-190 units/L	Sed. Rate			15 mm/hr
Cholesterol			<200 mg/dl	D-Dimer			<250-600 ng/mL
HDL LDL			>45 mg/dl 60-180 mg/dl	Bleeding Time			1-9 minutes
Triglycerides			35-160 mg/dl	Digoxin level			15-25 ng/mL

Abnormal Labs: Please document abnormal labs here. Add more lines if needed.

Date	Test/Finding	Result	Reason out of Norm

Pathophysiology

Treatments

Risk Factors

Nursing diagnosis

System		Finding	System		Finding
Cardiovascular	BP		GI	Abdominal Contour/Firmness
	Pulses (Bilaterally when applicable)			Bowel Sounds X 4 Quadrants
	Rhythm			Last BM
	Apical Rate			Bowel Program
	Radial			Dentition
	Capillary Refill		Urinary	Amount
	Heart Sounds S1, S2,S3,S4, Rub			Continent or Incontinent
	Murmur			Bladder Program
Respiratory	Rate		Skin	Integrity
	Rhythm			Hydration/Turgor
	Effort			Lesions/Scars/Wounds (Location and Descriptions)
	Pulse Oximetry			Edema (Location/Amount)
	Breath Sounds		M/S	Mobility/Strength
	LUL			Assistive Devices
	LLL			Immobilization Devices (Traction/Cast/Fixators)
	RUL		Neurologic	Temperature
	RML			LOC
	RLL			Speech
	Cough			Vision
	Secretions/Sputum Amount/Appearance			Hearing
	Mucous Membrane Color			Sleep Pattern
	O2 administration			GCS

PAIN

Location	Duration	Cause/Description	Pain Scale	Control Method/Management	Effectiveness of Relief

*Can finish this bottom part of page during Clinical

1. List other disciplines involved in the Patient’s Care:

2. Describe any need for assistance after discharge,

3. Describe and discuss patient teaching:

4. List what you taught or reinforced to the patient/family. Name of pamphlet or handout used (if applicable)

5. Name one of the resources that you looked up (can be a policy or procedure, research article, etc.)

Medication page

Medication: Trade and Generic names	Pharmacotherapeutic Classification & Drug Action	Normal Dosage Range	Amt. Dr. ordered	Route and Time	Why is Patient receiving medication?	Life threatening and most common reactions to monitor/observe	Nursing responsibilities
		HIGH LOW
		HIGH LOW
		HIGH LOW
		HIGH LOW
		HIGH LOW

# 1 Nursing Diagnosis _________________________________________________________

R/T AEB	Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long-term- measurable after clinical)	Nursing Actions (Interventions in order of priority)	Rationale for Actions	Evaluation of Interventions	Patient/significant/family educational needs
R/T: AEB:

# 2 Nursing Diagnosis _________________________________________________________

R/T AEB	Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long-term- measurable after clinical	Nursing Actions (Interventions in order of priority)	Rationale for Actions	Evaluation of Interventions	Educational needs
R/T: AEB:

# 3 Nursing Diagnosis _________________________________________________________

R/T	Patient’s Goals (label them short term or long term) Short term-must be measurable for the duration of clinical Long-term- measurable after clinical	Nursing Actions (Interventions in order of priority)	Rationale for Actions	Evaluation of Interventions	Educational Needs
R/T: AEB:
AEB

70-110 mg/dl

Gluc

K+

Cre

CO2

Ca++

Phos

Mg+

9-10.5mg/dl

1.3-2.1mEq/L

3-4.5mg/dl

5-10M/mm3

150-400 M/mm3

HCT

M 42-52%

F 37-47%

PT

PTT

11-12.5 sec.

30-40 sec.

INR

1.0-2.0

Medical Diagnosis