Please read through it. Thank you
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