PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED

NSG125FullCarePlanRevised11.17.23.docx

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Instructions:

During the NSG125 Transition to Professional Nursing course, students will complete a total of one care plan assignment as follows:

1. Care Plan based on a simulated client case from Shadow Health - OR

2. Care Plan based on a clinical site client.

Care Plan Map Components:

· Part I: Physical Assessment

· Part II: History & Physical

· Part III: Medications

· Part IV: Diagnostic Studies & Interpretation/Assessment Explanation

· Part V: Clinical Judgement Measurement Model Table

Rubric: Must achieve 16 points to pass clinical.

1. Care Plan based on a simulated client case- OR a Care Plan based on a clinical site client

Criteria	4 points	3 points	2 points	0 points	Total Points
Part I: Physical Assessment	All components of the physical assessment are present.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the assessment areas are lacking information.	Assessment information not provided
Part II: History & Physical	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part III: Medications	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part IV: Diagnostic Studies & Interpretation/Assessment Explanation	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part V: Clinical Judgement Measurement Model Table	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Total points	/20

Part I: Physical Assessment

VS Time: Temperature Pulse Respirations BP / Pain /10

GENERAL SURVEY
	Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic Height___________ Weight____________ Well-groomed Poorly Groomed Facial Expression: Content Happy Anxious Sad Angry Flat
NEUROLOGICAL
(LOC) Level of Consciousness	Alert Awake Lethargic Obtunded Stupor Comatose Confused Oriented x 4: If not alert X 4, circle what they are alert to: Person Place Time Situation
Eyes	Unaided sight Glasses Contact lens Blind
Pupils	Equal Round Reactive to light Accommodates List abnormal findings:________________________________________ Pupil reaction: Brisk Sluggish Nonreactive to light Pupil size: before light ______mm after light ______mm
Ears	Unaided hearing Hard of hearing Deaf Hearing aid Implant
Extremity Strength	Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
Pain	Location: Onset (when did it start): Provokes (makes it worse): Palliates (makes it better): Quality (description): Radiate: location: Severity: ___/10 Time: Constant Intermittent
CARDIOVASCULAR
Skin / Mucous Membranes	Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic
Radial and Pedal Pulses	Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent
Apical Radial Pulses	(2 assessed simultaneously) Equal Pulse Deficit
Capillary Refill	Normal (<3 Sec) ______sec Location:________________
Edema	Absent Present: location +1 +2 +3 +4 Non-Pitting
Heart Rhythm/ Sounds – S1S2	Heart Rhythm: Regular Irregular Heart Sounds: S1/S2 Murmur Extra Sounds Sound: Strong Distant
IV	None Solution_______________ Rate ____ml/hr Site location (be specific) ______________________________________ Site appearance: WNL Edema Erythema Tender Pallor Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________
RESPIRATORY
Respirations	Pattern: Regular Irregular Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction Chest Expansion: Symmetrical Asymmetrical
Lung Sounds	Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______ Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______
Cough	None Non-productive Productive Sputum: amount color
Oxygen	Room air O2 at_____L/min Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask
Respiratory Treatments	Incentive Spirometer (IS): ml______ # of times______ Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________
GASTROINTESTINAL
Oral	Mouth: Teeth Dentures Caries Swallowing: Gag reflex Dysphagia Mucous Membranes: intact moist dry pale pink
Abdomen:	Contour: Soft Round Flat Scaphoid Obese Palpation: Firm Hard Tender Non-Tender Location: Distention: Nondistended Distended
Bowel Sounds	RLQ Normoactive Hypoactive Hyperactive Absent RUQ Normoactive Hypoactive Hyperactive Absent LUQ Normoactive Hypoactive Hyperactive Absent LLQ Normoactive Hypoactive Hyperactive Absent
NG/ GT/ JT	None Type of tube _____ patent non-patent Purpose: Suction Feeding Medication Administration Type of food: _________ Fluid Flush__________mL
Bowel Movement	Continent Incontinent Last BM__________ Color Consistency Ostomy: yes no
Nutrition	Self-feed Needs assistance Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________ Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed Tube Feed: Yes or No
GENITOURINARY
Urine	Continent Incontinent Urgency Hesitancy Frequency Burning Nocturia Catheter type _______________ None Color_________________ Clear Cloudy Sediment Burning Frequency
Intake and Output	PO/Oral/Tube Feed intake____________ mL IV intake____________ mL Urine output_________ mL Other output_________ mL Fluid restriction ___________mL/day
MUSCULOSKELETAL
ROM	Active ROM: Completed____________ Passive ROM: Completed____________
Mobility	Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair Walks: distance frequency tolerance PT OT
Other Musculoskeletal	Cast: Location: Brace: Type: Location: Amputation: Location:
Risk for Falls	Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board
INTEGUMENTARY
Appearance	Color: Normal for Ethnicity Pallor Rash Bruise Lesions Intact OR Non-Intact: Location of Non-Intact Areas_____________________________________________________ New Scars: Location _________________________ Dressing change: (describe: location, steps, drainage, wound)
Temperature and Moisture	Temperature: Warm Hot Cool Cold Moisture: Dry Moist
Incisions/Wound	None Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________ Wounds Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough
PSYCHOSOCIAL
Behavior	Cooperative Uncooperative Pleasant Withdrawn Combative Other_______________
Language spoken	English = speaks and understands other_________________ Interpreter

Part II: History and Physical
Nursing Care Plan:	Date:
A. Client identifiers: Physician (s): Age: Gender: Ht: Wt. Code Status: Isolation Status:
Health States
Date of admission: Activity level: Diet: Fall risk: Client’s chief complaint: Client’s past medical and surgical history Allergies:	Mobility needs: (Independent, partially-dependent, full-assist) Interdisciplinary Consults (PT/OT/RT/ST/other): Referrals to Specialists (pulmonary, cardiac, neuro, etc.)
Socio-cultural Orientation
Cultural and Ethnic Background Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, and financial abuse) Barriers to independent living

Part III. Medications
List medications, dosages, classifications, and the rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication. A maximum of twelve (12) medications focus on the medication corresponding to the patient’s primary and chronic health conditions.
ALLERGIES:
Medication, Classification, Mechanism of Action	Dosage/Route	Contraindications, Adverse Reactions/Side Effects, Risk Factors,	Client Education and Nursing Implications	Why is this client getting this medication?

PART IV: Diagnostic studies and Interpretation (Maximum of 5 lab values)
Labs	Normal Values	Results	What do these results indicate?	Identify 2 interventions based on the laboratory findings (examples: Medications, procedures, positioning)

Assessment Explanation
Identify three (3) nursing interventions based on the Physical Assessment findings	1.
	2.
	3.
State the educational needs of this client.	1.
	2.
	3.

NSG125 Transition to Professional Nursing- Care Plan

9 Revised:11/17/2023

PART V: Clinical Judgement Measurement Model Table

Recognize Cues

Identify five (5) abnormal Signs, symptoms, risk factors, labs, and health history, clinical manifestations.

Prioritize

Using the Recognize Cues column to prioritize the chief complaints

Generate Solutions

List three (3) nursing interventions needed for this client. Use the three (3) interventions identified above.

Evaluate Outcomes

How would you determine the effectiveness of your nursing interventions?