Nursing Care Plan: Basic Conditioning
| Nursing Care Plan: Basic Conditioning Factors | |
| A. Patient identifiers:
Age: Gender: Ht: Wt. Code Status: Isolation: |
Development Stage (Erikson): Give the stage and rationale for your evaluation
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| Health Status | |
| Date of admission:
Activity level: Diet: Fall risk (indicate reason)
Client’s description of health status
Allergies: (include type of reaction)
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Reason for admission:
Past medical history that relates to admission: |
| Socio-cultural Orientation | |
| Cultural and Ethnic Background with current practices:
Socialization:
Family system: (Support system)
Spiritual:
Occupation: (across the lifespan)
Patterns of living: (define past and current)
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| Barriers to independent living:
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| Healthcare systems elements (continued) ALLERGIES: | |||||
| Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.
DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication? Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference |
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Oxytocin |
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Carboprost (Hemabate) |
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Methergine |
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Misoprostol (Cytotec) |
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| LAB | Normal Range | Value/ Date | Clinical Significance | Nursing Assessments/ Interventions Required |
| HEMATOLOGY | ||||
| CBC | ||||
| WBC | ||||
| RBC | ||||
| HGB | ||||
| HCT | ||||
| PLATLETS | ||||
| Diff: | ||||
| Polys | ||||
| Bands | ||||
| Lymphs | ||||
| Mono’s | ||||
| Eosin | ||||
| GBC indices | ||||
| MCV | ||||
| MCH | ||||
| MCHC | ||||
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SEROLOGY |
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| HIV | ||||
| GBS | ||||
| Gonorrhea/ Chlamydia | ||||
| Syphilis | ||||
| Hepatitis B | ||||
| Rubella | ||||
| BLOOD TYPE | ||||
| RH FACTOR | ||||
| Universal Self-Care Deficits: Assessment: (Highlight all abnormal assessment findings) | ||||||
| Vital Signs | Admission | Reassess | ||||
| Input: | ||||||
| Output:
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| Cardiovascular Assessment:
Specialty devices:
Teaching needs: |
Heart Sounds:
Circulatory Assessment:
Edema: |
Pain assessment: (PQRST)- Specific area | ||||
| Respiratory assessment
Special devices:
Teaching Needs: |
Lung sounds:
Pulmonary assessment: (respiratory pattern) |
Cough:
Respiratory treatment and rational for use: |
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| Breast assessment:
Teaching Needs: |
Breast Assessment:
Nipple assessment:
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Breastfeeding plans:
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| Uterine Assessment:
Teaching needs: |
Location:
Firmness: |
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| GI Assessment:
Teaching needs:
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GI assessment: (observe – auscultate – palpate)
Alteration in eating or elimination patterns:
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Nutrition Metabolic Assessment:
% of diet taken:
Alternative nutritional methods:
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| GU assessment:
Teaching needs: |
Last void:
Due to void: Alternative urinary elimination method: (if Foley when inserted)
Bladder scan |
Assessment of urinary patterns:
Urine assessment (color odor concentration etc.)
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| Lochia Assessment:
Teaching needs:
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Color:
Quantity:
Presence of clots: |
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| Perineal Assessment:
Teaching needs:
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REEDA:
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Wound Care:
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| Thrombophlebitis Assessment:
Teaching needs:
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| Edema Assessment:
Teaching needs:
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| Emotional Assessment:
Teaching needs:
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Edinburgh Postnatal
Depression Screening: |
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| IV Therapies:
IV fluids infusing
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IV Site 1: Assessment
Date of insertion: Change (site or dressing)
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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 SPECIFICALLY HER RESPONSE.
CONCEPT MAP-
Nursing Process Care Plan (Example)
| Assessment/recognize cues (what is outside normal limits, use measurements)
What data are relevant and must be interpreted as clinically significant by the nurse?
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Nsg Diagnosis (not medical diagnosis)/ analyze cues –interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far? | Prioritize a hypothesis/ Create a Plan and rationale:
(to do first-which one is the most pressing and why? Rank them by urgency: What problem is most likely present? Most concerning? |
Generate solutions/goals (what level of improvement are we working towards, make it measurable) collect additional data? | Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve? | Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Was our goal met? Did our intervention help? What additional clinical decisions need to be made |
| Assessment #1
Patient reports SOB (subjective data)
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Nsg Diagnosis
Impaired gas exchange? Impaired airway? need to obtain O2 (84%) RR (24) lung sounds (exp wheezes) |
Plan:
#1 is most concerning due to ABCs matrix) |
Goals
improve oxygenation Is this an airway issue-blockage? Discover client has history of COPD, had pneumonia two months ago, |
Intervention #1a
Raise HOB to 45-90 to improve lung expansion |
Evaluation #1:
O2 trended up to 89% on 2L RR trended to 22 Lung sounds cleared with coughing but wheezing returns with bedrest. Goal partially met
Need to call provider with findings, request CXR, and foresee possible Antibiotics |
| Intervention #1b
NC 2L O2 to increase oxygen saturation of inhalation |
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| Intervention #3c
Education about TCDB q1 hour while awake to clear the airways for better ventilation |
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| Assessment #2
Patient reports pain 4/10 |
Nsg Diagnosis
etc |
Plan:
etc |
Goals
etc
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Intervention #2a
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Evaluation #2: |
| Intervention #2b
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| Intervention #2c
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| Assessment #3
Patient has new redness to coccyx |
Nsg Diagnosis
etc
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Plan:
etc |
Goals
etc
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Intervention #3a
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Evaluation #3: |
| Intervention #3b
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| Intervention #3c
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Nursing Process Care Plan For Client in Student’s Care (observe, take note, create
| Assessment/recognize cues (what is outside normal limits, use measurements)
What data are relevant and must be interpreted as clinically significant by the nurse?
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Nsg Diagnosis (not medical diagnosis) /analyze cues -interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far? | Prioritize a hypothesis/Plan and rationale:
(which are we doing first-which one is the most pressing and why? Rank them by urgency? What problem is most likely present? Most concerning? |
Generate solutions/goals ((what level of improvement are we working towards, make it measurable) collect additional data? | Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve? | Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Did our intervention help? What additional clinical decisions need to be made |
| Assessment #1
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Nsg Diagnosis
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Plan:
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Intervention #1a
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Evaluation #1:
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| Intervention #1b
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| Intervention #1c
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| Assessment #2
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Nsg Diagnosis
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Plan: | Intervention #2a
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Evaluation #2: | |
| Intervention #2b
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| Intervention #2c
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| Assessment #3
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Nsg Diagnosis
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Plan: | Intervention #3a
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Evaluation #3: | |
| Intervention #3b
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| Intervention #3c
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