Care plan and concept map

Basic Adult Health Care Plan

First MI Last Name

Department of Nursing, Keiser University

NUR 1211C Basic Adult Health

Instructor Name

Due Date of Paper

Student Name: Date:

Client Data:
Initials:	Age:	Gender:
Weight:	Height:	Race/Ethnicity:
Diet:	Religion:	Language Spoken:
Allergies:	Marital Status:	Code Status:
Past Surgeries:	Consults:	Social Habits:
Vital Signs:
B/P:	P:	R:	T:	SAO2 sat:

Present History: Admitting Medical Diagnosis:

A. Why client is in hospital:

Medical diagnosis (does not include signs and symptoms) Look for this information in the H&P under the plan heading

Admitting Diagnosis Information:

This paragraph should describe what the signs and symptoms that caused patient to come to the hospital. It should not be what the doctor writes word for word. Paraphrase-put into your words. You may quote the patient.

Definition/Etiology/Pathophysiology:

This paragraph is to define and explain the admitting diagnosis/disease.

This paragraph should explain the etiology. The etiology is what causes the disease.

This paragraph should explain the pathophysiology of the patient’s disease. Pathophysiology describes what the disease does to the body.

Clinical Manifestations/Signs and Symptoms:

This/these paragraphs should explain what the textbook manifestations are and whether signs and symptoms of the patient are similar or different.

Medical Management:

This/these paragraphs should explain the textbook medical management for the admitting diagnosis disease. What medical management is currently being done for the patient?

Past History/Secondary Diagnosis:

Name an additional diagnosis that the patient has.

Definition/Etiology/Pathophysiology:

Complete definition/etiology and pathophysiology for the secondary diagnosis as above.

Clinical Manifestations/Signs and Symptoms:

Complete clinical manifestations and signs and symptoms for secondary diagnosis as above.

Medical Management

Complete the medical management of the secondary diagnosis as completed above.

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BAH Care Plan

List of Medications

Medication Name/Dosage/ Frequency/ Route	Indications	Actions	Contraindications	Side Effects	Nursing Implication
You will need to address minimum of eight medications that pertain to this patient’s disease. Choose medications that treats the admitting diagnosis, secondary diagnosis and past medical history, not medications ordered as part of the power plan.	Be sure to summarize information and not copy word for word out of the drug book.	Also, information should be specific to the patient in which this care plan is written		Be sure to cite from where you received your information	Assessment: Patient/Family Teaching: Your pharm book is an excellent resource to use for nursing implication information.
		.

Labs and Diagnostic Test:

Labs And Diagnostic Test/Labs	Purpose/ Indications	Normal Values	Client Result	Interpretation of Abnormal Results
I want to see abnormal labs or diagnostic tests that is related to why the patient is in the hospital.	Why would the physician order this diagnostic lab/test (? Signs/symptoms, history, etc) Cite reference	Patient specific (male vs female, age/race, etc) What is LRH’s normal range?		Patient specific-what could be concerns related to abnormality
				.

Nursing Diagnosis Two

This is where you will write your second nursing diagnosis.

Nursing Interventions

Discuss three nursing interventions that go with the second diagnosis.

Nursing Rationales

Discuss three rationales that go with each intervention.

Nursing Diagnosis Three

This is where you will write your third nursing diagnosis.

Nursing Interventions

Discuss three nursing interventions that go with the third diagnosis.

Nursing Rationales

Discuss three rationales that go with each intervention.

Nursing Assessment: head to toe physical assessment including IVs, tubes/drains/wounds if appropriate

Labs:

Diagnostic tests:

Plan/NOC – Patient will ______________ as evidenced by_______, _______, ________, ________.

Goals: Written as SMART goals (specific, measurable (action verbs), attainable, realistic, timed)

Minimim 2 short term goals, 1 long term goal

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Evaluation:

Goal met or not met, continue, discontinue, or reevaluate. Explain each evaluation. Match each evaluation to the goals written above.

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Nursing Diagnosis: Written in NANDA format: ___________ related to ____________ as evidenced by ____________.

Rationales

Rationale for nursing intervention. Must match each intervention written.

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Interventions:

What are your nursing interventions so patient can meet goals written above? Must match goals above.

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Problem:

What is wrong with your patient?

References

Written in 7th edition APA format. All referenced citations should be found on this page.

Owl.purdue.edu or Keiser library is a good resource to use to appropriately document references and citations.