nursing care plan

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Nursing Clinical Packet

Patient Assessment and Care Plan

Instructions to student:

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1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly.

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 PATIENT ASSESSMENT FORM

STUDENT NAME: DATE:
CLIENT INITIALS: ROOM # DOB: AGE GENDER: ADMISSION DATE:
CODE STATUS: ALLERGIES: MARITAL STATUS: OCCUPATION (FORMER):
MEDICAL DX: CHIEF COMPLAINT:
PAST HISTORY (SURGERY/PROCEDURES) WITH DATES
ORDERS RATIONALE (Why is this ordered for this client???)
EXAMPLE: DIET 2 g Sodium diet with nectar thick liquids only Sodium is restricted due to edema in the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke.
DIET
ACTIVITY
I/O
VS
BGM
FOLEY
NG
PEG/PEJ TUBE
WOUND CARE
RESPIRATORY TREATMENT
TRACHEOSTOMY
SUCTIONING
CHEST TUBE
SPECIAL EQUIPMENT
LAB ORDERS
OTHER
REHAB SERVICES ACTIVITY OR TREATMENT PLAN & SCHEDULE RATIONALE
PHYSICAL THERAPY
SPEECH THERAPY
OCCUPATIONAL THERAPY

/ 5 pts

IVs

IV FLUID AND RATE: SITE LOCATION AND CONDITION:
LAST DRESSING CHANGE: LAST TUBING CHANGE:
GAUGE: REASON FOR IV ACCESS:
DIAGNOSTIC TESTS: DATE RESULTS REASON FOR TESTING AND IMPLICATIONS FOR NURSING CARE
LAB TEST DATE RESULTS NORMS REFERENCE RANGES IMPLICATIONS FOR NURSING CARE (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP IMPROVE AN ABNORMAL RESULT?)

GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development)

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO HAVIGHUSRT TASKS OF THIS STAGE:
ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF TASKS

/ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below.

Brand Name and Generic Name Normal Dosage Ranges Contraindications
Coreg (carvedilol) 3.125 mg – 50 mg BID Asthma, heart block
Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions
β-adrenergic blocker 6.25 mg p.o. BID Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
He has a history of hypertension but has been taking Coreg for 2 years to control his hypertension BP’s for past 3 days have been 128/78, 132/72, 138/80How is this medication impacting your client??B/P readings, lab results, pain management, etc…….. Do not discontinue abruptly or before surgeryCaution with Upper airway dysfunctionRise slowly to minimize orthostatic hypotension, check B/P and heart rate prior to administrationTake before meals
#1 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#2 Brand Name and Generic Name Normal Dosage Ranges Contraindications
#3 Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#4 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#5 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
# 6 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#7 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#8 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#9 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#10 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#11 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching
#12 Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage, Route and Frequency Adverse Reactions
Why this Patient Receives this Med Effects of the Med on the Client Nursing Considerations and Teaching

/ 20 pts

NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments. We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long term care resident follows below.

TEMP: APICAL HR: RESP: BP: HT: WT:
DATE / TIME (TYPE HERE)

Sample Narrative Note — Head to Toe format

Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145
12/22/2010 1400 Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without erythema or exudate. No chewing or swallowing difficulties. 75% of general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal. Motor and sensory functions grossly intact. No weakness or paralysis. Upper extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion. Apical pulse regular (rate) and rhythm. Double lumen picc line note to left antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this morning, passed a large, soft- formed brown stool and a moderate amount of clear yellow urine. Bilateral lower extremities, no tenderness, swelling or joint deformities noted. Denies numbness or tingling to extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses palpable and equal bilaterally.

PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down your assessment findings.)

ROUTINE FINDINGS PATIENT VARIATIONS/ABNORMALS
COGNITION/NEUROLOGICAL (SAMPLE) Alert and oriented x3, recent and remote memory intact. Denies any numbness or tingling to extremities” (SAMPLE) “Fine resting tremor of left hand
SKIN
SENSORY Wound measurements and complete description if available at the very least Document dressing including the type of dressing and description of condition!
BREASTS – DEFERRED.
RESPIRATORY – (Include ventilator settings as indicated in narrative note)
CARDIOVASCULAR Include any vascular access device, IV lines, AV fistulas, perma -cath lines, etc.
ABDOMEN –. Include any enteral feedings here and routeBOWEL CONTINENCE? LAST BM? BOWEL PLAN?
MUSCULOSKELETAL –
GENITOURINARY – URINARY CONTINENCE? TOILETING PLAN?
PELVIC – DEFERRED.
RECTAL – DEFERRED.

/ 10 pts

1

NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at least 10) and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be priority 1, 2, or 3!!!!!

Expectation is to have at least 10 nursing diagnosis listed!

# List the Client problem An appropriate Nursing Diagnosis stem(REFER TO YOUR NURSING DIAGNOSIS LIST) Related to part of the statement (This is individual to your client) As evidenced by part of the statement (This is individual to your client)REMEMEBR THIS IS NOT USED IN A “Risk For” diagnosis
1 SAMPLE: Reports severe pain in the right hip. “Acute Pain” “related to” fractured right hip “as evidenced by” verbal report of pain rated at an 8 on a scale of 0 –to 10.
2 SAMPLE: Complete bed rest “Risk for Impaired skin integrity” “related to “ immobility NONE it is a “Risk for” diagnosis so there is no evidence statement

From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.

SAMPLE NCP

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal report of pain rated 8 on a scale of 0 -10.
ASSESSMENT(Data that directly pertains to the above nursing diagnosis) OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time) INTERVENTIONS(Individualized, specific, frequency)Minimum of 4-5 interventions per plan SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source) EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA: “My right hip hurts me so much every time I move. I am so afraid to start physical therapy” SHORT TERM: Client will report pain level rated at a 3 or lower 30 minutes after pain medication taken 1. Educate the client on the importance of pain relief to enhance her rehabilitation efforts and include education on various types of methods to relieve pain.2. Encourage client to express any questions or concerns she may have regarding pain management methods to alleviate anxiety and fears.3. Educate the client on her responsibility to honestly report pain when it occurs as well as reporting if the current pain management is effective or ineffective for providing her pain relief4. Provide for alternative/complementary measures of pain relief, such as, reduce lighting and noise, soothing music, pet therapy, massage, and hot/cold packs according to client preferences. 1. “There are many ways to manage pain. In addition to pharmacologic and non-pharmacologic measures, simple nursing interventions can alter patients’ pain experience and speed their recovery.” Taylor, Lillis and White pg. 1168.2. “Common fears include a loss of control and embarrassment by being unable to deal with pain maturely… The patient may view the need of for medication as a sign of weakness or may fear addiction or loss of effectiveness at a later date.” Taylor, Lillis and White pg. 1169.3. “As a patient advocate, ensure that a strong emphasis on the need for aggressive, individualized strategies that can minimize or eliminate acute pain and improve patient outcomes. Preventing pain is easier then treating it once after it occurs.” Taylor, Lillis and White pg. 1178.4. Alternative/complementary measures will provide an added benefit of distraction from pain experience and augment analgesic effect. Cold/hot therapy can provide constriction and or dilation which will reduce pain inflammation in each specific circumstance Daniels. Pg 378 Short Term Goal: Met; pain was rated at a 2 on a scale of 0 to 10 after administration of Vicodin.Long Term Goal. In progress
OBJECTIVE DATA:Alert and oriented 70 year old widowed female. Lives in an apartment independently. 2 daughter live nearby and visit often.History of a fall while out shopping 1 ½ weeks ago. Right hip surgically repaired 7 days ago. Surgical dressing to right hip is clean, dry and intact. Circulation, motion and sensation intact to right lower extremity.Afebrile; BP 124/80; R-18 AP 84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears eye glassesMedical history positive for osteoarthritis and osteoporosisNon weight bearing to right leg and to use a walker for ambulationTo start physical therapy for gait and strength training BID times 7 days and occupational therapy to develop upper body strength once daily times 7 daysReports pain level is at 8 on a scale of 0 to 10.Has Vicodin 5mg/325 mg po 2 tabs every 4 hours prn for severe painIbuprofen 400 mg every 6 hours prn for moderate pain. LONG TERM: Client will report pain level of 2 or less using ibuprofen with alternative pain control methods by discharge.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:
ASSESSMENT(Data that directly pertains to the above nursing diagnosis) OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time) INTERVENTIONS(Individualized, specific, frequency) SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source) EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA: SHORT TERM:
OBJECTIVE DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:
ASSESSMENT(Data that directly pertains to the above nursing diagnosis) OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time) INTERVENTIONS(Individualized, specific, frequency) SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source) EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA: SHORT TERM:
OBJECTIVE DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:
ASSESSMENT(Data that directly pertains to the above nursing diagnosis) OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time) INTERVENTIONS(Individualized, specific, frequency) SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source) EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA: SHORT TERM:
OBJECTIVE DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

3

Key Problem: Impaired urinary elimination

Data:

Intake=3800 Output=3200

Polyuria

3+ glucose in urine

AEB: Polydipsia and polyuria

Outcomes:

Pt. will have urine output of 1000 – 2000 ml/24 hours.

Interventions:

Monitor I & O q shift.

Monitor BGM a.c. and h.s.

Monitor kidney function tests

Administer antihyperglycemics as ordered.

Key Problem: Knowledge deficit

Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine

AEB: Verbal statements and questions.

Outcomes:

Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique by discharge.

Interventions:

Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style.

Provide information q shift according to teaching plan recorded in EMR and document pt’s response.

Reassess level of knowledge daily.

Provide written information.

Provide educational resources available in the community.

4

Medical Problems (Pathophysiology)/Surgical Procedures:

Newly diagnosed diabetic

Key Assessments:

S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals

Tests: FBS, hemoglobin A1C

“I don’t know how this fits”

Recent widow

Kids live out of state

? support system

1

Key Problem: Acute anxiety

Data: Restless, verbally states she is anxious.

AEB: Pt states “I don’t know what I will do with diabetes, this is too much.”

Outcomes: Pt. will verbalize under-standing of resources available by discharge.

Interventions:

Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions.

Demonstrate progressive relaxation exercises and have pt. return demonstrate.

Provide pt. with a list of community resources for newly diagnosed diabetics.

Identify client’s perception of anxiety

Utilize empathy.

2

Past Medical History: Hypertension x 20 years; appendectomy at age 9.

Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary lifestyle; 290 pounds, age 52

Key Problem:

Imbalanced nutrition, more than

Data:

BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs

AEB: Anthropometric measurements.

Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior to discharge.

Interventions:

Assess client’s knowledge of nutrition and its relationship to diabetes.

Arrange for dietary consultation.

Reinforce teaching by dietician.

Encourage physical activity as a weight loss strategy.

Provide pt with community resources that can assist her with weight loss goal.

“I DON’T KNOW HOW THIS FITS”

PAST MEDICAL HISTORY

RISK FACTORS

MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:

KEY ASSESSMENTS:

Key Assessments:

Tests:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

RUBRIC for Grading Packets

/60pts

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

Student Name: Clinical Date: Site:
Section Grading Criteria Satisfactory Or Unsatisfactory Comments, Kudos,Things to Improve for Next Time
10 pointsPatient Demographics,Diagnoses, Surgeries, Orders, Rehab, IV, Imaging and Lab Page 1 fully and correctly completed 5 ptsPage 2 fully and correctly completed 5 pts _/5____/5___
20 pointsMedications Medication Trade Name 2 ptsMedication Generic Name 2 ptsPharmacological Classification 2 ptsNormal Dosage Range 2 ptsDose ordered 2 ptsRoute and Frequency 2 ptsContraindications 2 ptsAdverse Effects/Reactions 2 ptsNursing Considerations & Teaching 2 pts(Legible or typed) 2 pts / 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2_/20__
10 pointsNarrative NotesHead-to-Toe Assessment Narrative note is in Head to Toe orderHead-to-toe assessment documented Abnormal results noted 10 pts ___/10_
60 points (either a Concept Map or a Patient Care Plan)Concept Map Correct Medical Diagnosis 15 ptsPathophysiology 15 ptsKey Assessments 15 ptsAt least 3 problems identified 15 pts ____/60OR
60 points (either a Concept Map or a Patient Care Plan)Patient Care Plan 3 nursing diagnoses Related to” “As evidenced by” 18 pts2 Outcomes specific, measurable, timed 8 pts4-5 Interventions are logical, appropriate 15 pts4-5 Scientific Rationales supporting each intervention 15 pts 2Evaluations 4 pts ____/60

 

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