Care plan template

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Name: Date:

Care Plan #

Nursing Care Plan- Basic Conditioning Factors

Patient identifiers:

Age: 68 Gender: M Ht: Wt. Code Status: DNR

Isolation: “N/A”

Development Stage (Erikson): Give the stage and rationale for your evaluation

Health Status

Date of admission: 08/16/2022

Activity level: Bedbound Diet: Mechanical soft, thin liquid

Fall risk (indicate reason): Yes.

Client’s description of health status:

Allergies: (include type of reaction) No known allergies

Reason for admission: AMS, PE, UTI, Aspiration PNA

Past medical history that relates to admission:

Renal insufficiency, HTN, BPH, DM, Anemia, Vital D deficiency, Unspecified hereditary retinal dystrophy, chronic diastolic (congestive) heart failure, Adjustment disorder with mixed anxiety and depressed mood, anemia unspecified, unspecified dementia, severe, with other behavior disturbance, Type2 diabetics mellitus with hyperglycemia, Hyperlipidemia unspecified, chronic kidney disease stage 3B with heart failure and stage 1, obstructive and reflux uropathy, unspecified hearing lost, unspecified psychosis not due to a substance or known, Visual field defect.

Socio-cultural Orientation

Religious, Cultural and Ethnic background with current practices: White

Socialization: Family visit

Family system (support system): Brother

Spiritual: Uknown

Occupation (across the lifespan):

Patterns of living (define past and current):

Barriers to independent living:

ALLERGIES:

Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following:

1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication?

Medication Classification Dosage & Route Rationale Possible Negative Outcomes

Ferrous sulfate tablet 325mg

325mg, one tablet by mouth two times daily

(crush)

Alprazolam

0.25mg, by mouth every 8 hours as needed

Anxiety

Zinc Oxide Ointment

2O% Apply to the sacral area every shift

Skin condition

Potassium Chloride Packet

20MEQ 1packet by mouth in the morning

Hypokalemia

QUEtiapine Fumarate tablet

25mg by mouth at bedtime

Psychosis

Apixaban tablet

2.5 mg by mouth two times a day

For DVT prophylaxis

Omeprazole Capsule

40mg 1 capsule by mouth

For GI prophylaxis

Senna-Docusate Sodium

8.6-50mg by mouth at bedtime

For bowel management

Cholecalciferol

1000 unit 2 tablets by mouth one time a day

For vitamin D insufficiency

Simethicone

80 mg 1 tablet by mouth every 4 hours

For gas

Ondansetron HCI

4 mg 1 tablet by mouth every 6 hours PRN

For Nausea and vomiting

Gabapentin capsule

100 mg 1 capsule by mouth three times a day

Traumatic ischemia of muscle

Acetaminophen

325 mg 2 tablets by mouth every 6 hours

For pain management

MiraLAX powder

17 GM/Scoop 1 scoop by mouth one time a day

Bowel management

CONCEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis

Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies).
What symptoms does your client present with?

Complications

Treatment (Medical, medications, intervention and supportive)

Risk Factors (chemical, environmental, psychological, physiological, and genetic)

Nursing Diagnosis

Problem statement (NANDA diagnosis):

Related to (What is happening in the body to cause the issue?):

As evidenced by (Specific symptoms):

.

03/03/2023

LAB VALUES AND INTERPRETETION

LAB

Range

Value

Value

MEANING (If WDL then explain the possible reason for the lab)

LAB

Range

Value

Value

MEANING

HEMATOLOGY

CHEMISTRY

CBC

Glucose

WBC

3.6-11.2

11.5

H

BUN

7-23

29

H

RBC

3.7-5.5

3.5

L

Cr

HGB

12.0-18.0

9.5

L

GFR

HCT

36.0-52.0

31.5

L

Na

PLATLETS

150.0-450.0

457

H

K

Diff:

CO2

23-31

32

H

Polys

Ca

8.3-10.5

8.2

L

Bands

Phos

Lymph

14.0-46.0

13.2

L

Amylase

Mono

Lipase

Eosin

Uric Acid

GBC indices

Protein

MCV

Albumin

3.3-5.0

2.9

L

MCH

Cl

MCHC

31.6-36.9

30.2

L

Enzymes

COAGs

LDH

PT

CPK

INR

SGOT

PTT

SGPT

ABGs (V or A)

Troponin I

PH

Myoglobin

PCO2

PO2

Cholesterol

BASE EX:

SAT:

URINALYSIS

Range

Value

Value

Meaning

Others not listed:

Findings

Meaning

Color

Gastroccult

Clarity

Hemoccult

Sp. Gravity

pH

EKG

Protein

Glucose

CT Scan

Ketones

Bilirubin

Occ. Blood

MRI or MRA

Urobilinogen

WBC

RBC

Epithelia

Ultrasound

WBC

RBC

Epith Cell

Bacteria

Hyaline Cast

Gran Cast

Bedside Procedures:

Leukocytes

Nitrite

ACCUCHECKS

Additional information:

Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment findings)

Vital Signs

Time:

Time:

Oxygenation/ Circulation

Intake:

SpO2

1. 96 2. 3.

Accu-check

1. 153 2. 284 3. 4.

Output:

Cardiovascular Assessment

Specialty devices:

Teaching needs:

Heart Sounds: Regular rate/rhythm

Skin Temp/Moisture/Color: Dry

Edema: Not Applicable JVD:

Peripheral Pulses:

Pain assessment (OPQRST)

Rating:

Location:

Respiratory Assessment

Special devices:

Oxygen:

Teaching Needs:

Lung sounds:

Anterior:

Posterior:

Respiratory effort: Respiratory pattern: Reg/Irreg

Cough:

Respiratory treatment:

Medication(s):

Frequency:

Rationale for use:

Neurological Assessment:

Assistive devices
:

Teaching Needs:

Level of Consciousness: Alert / Verbal / Pain / Unresponsive

Orientation: Person / Place / Time / Events

Fine motor function:

Gross motor functioning:

Sleep patterns (During admission):

Sleep patterns (at home):

GI Assessment:

LBM (include description):

Teaching needs:

Abdominal Assessment: (observe – auscultate – palpate)

Alteration in eating or elimination patterns:

Nutrition Metabolic Assessment:

% diet taken:

Alternative nutritional methods:

GU assessment:

Teaching needs:

Last void:

Due to void:

Alternative urinary elimination method: (if urinary catheter in place, when inserted)

Bladder scan

Assessment of urinary patterns:

Urine assessment (color odor concentration etc.)

LMP

Integumentary Assessment:

Teaching needs:

Color/ Mucous membranes

Hydration:

Wound Care:

Not Applicable

Condition of skin: Dry, left upper arm bruise

Nutritional Assessment:

Teaching needs Need assistance with feeding

Diet: Mechanical soft

Eating patterns: By mouth

Insulin administration: Yes

Treatment of hypoglycemia:

Alternative feeding patterns:

IV Therapy

IV fluids infusing:

Rate:

Tubing dated?

IV Site Assessment: Location Not Applicable

Date of insertion: Change (site or dressing)

Not Applicable

IV removal:

Reason for removal:

Additional information:

REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS THE SPECIFIC RESPONSE.

PLAN OF CARE:
Use your top “2” priorities

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom)

Manifested by: (Specific symptoms)



Short term goal

: Create a SMART goal that relates to hospital stay.



Long term goal
: Create a SMART goal that is appropriate for discharge.

This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)

Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)

Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom?)

Manifested by: (specific symptoms)

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)

Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)

Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?

Nursing Care Plan 2

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