Nursing Care Plan
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CHC
Nursing Care Plan
STUDENT NAME: | DATE: | COURSE: | |
CLIENT INITIALS: | DATE OF ADMISSION: | AGE: | GENDER: |
HT: | WT: | ALLERGIES: | |
CODE STATUS: | |||
RACE/ETHNICITY: | CULTURAL CONSIDERATIONS: | ||
RELIGION/SPIRITUAL CONSIDERATIONS: | |||
OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES: | |||
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc) | |||
SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics) | |||
I. ADMITTING MEDICAL DIAGNOSIS: | |||
Definition: | |||
Etiology/pathophysiology: | |||
Common signs/symptoms: | |||
Potential complications: | |||
II. SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses such as DM, COPD, etc) | |||
Definition: | |||
Etiology/pathophysiology: | |||
Common signs/symptoms: | |||
Potential complications: | |||
III. SECONDARY MEDICAL DIAGNOSIS: | |||
Definition: | |||
Etiology/pathophysiology: | |||
Common signs/symptoms: | |||
Potential complications: | |||
IV. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)
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V. PAST MEDICAL/SURGICAL HISTORY: | |||
VI. SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed and explanation) | |||
VII. COMPLICATIONS R/T TO ABOVE: | |||
VIII. CONSULTS: (include date and reason for consult) | |||
IX. DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test, and results) |
X. LABS:
Lab Test | Purpose | Normal Values | Client Results | Interpretation of Abnormal Labs |
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XI. MEDS:
Medication
(Brand and Generic Names) |
Classification | Prescribed Dose,
Freq, Route |
Mechanism of Action | Patient Specific Indications
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Side effects/Nursing Implications |
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XII. IV FLUIDS: | Solution | Rate | Tonicity | |||
XIII. IV SITE(S): | ||||||
XIV. PT/OT | ||||||
XV. RESP TX: | Frequency | Type | Rationale | |||
XVI. NURSING INTERVENTIONS: (frequency, type, description, and/or N/A)
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VS: | date/time | temp /route | bp | p | r | |
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Pain level: | 0-10 scale | Location | PQRST | |||
Neuro checks: | ||||||
Cardiac monitor: | Pacemaker/ICD: | Hemodynamic monitoring: | ||||
Oxygenation: | Method of Delivery | Flow | Rate | Pulse Oximetry | ||
Vent settings: | Mode | TV | FiO2 | Rate | PEEP/CPAP | |
ABGs: | Suctioning: | Method | Frequency | Result | ||
Nutrition:
Weight: |
Diet | Appetite | Tolerance | Wt gain/loss | Dentition | Chewing/
Swallowing |
Enteral feeding: | Route | Indication | Formula | Rate | Tolerance | |
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Glucose (FS or lab) | |
Bowel/bladder elimination: | I&O: | |||||
Foley | NG | Ostomy | Drains | Other tubes | ||
Dressing/wound care: | Location | Appearance | ||||
Mobility: | ||||||
Ortho: (traction, cast, etc) | Activity/assistive aids: | |||||
Safety considerations: | Restraints: (date, type and justification) | |||||
Sleep/rest: | Hours | Quality | Aides |
XVII. HEAD-TO-TOE ASSESSMENT:
Neuro:
HEENT:
Resp:
C/V:
GI:
GU:
Reproductive: (Maternal to include breasts, fundus, peritoneum, and lochia)
M/S:
Skin/hair/nails:
Psychosocial: (include affect)
XVIII. NURSING DIAGNOSES: (minimum of 5, prioritized)
1.
2.
3.
4.
5.
XIX. NURSING CARE PLAN: Directions:
1. Formulate a NCP using (3) nursing diagnoses:
a. Two (2) are the priority nursing diagnoses from the above list.
b. The 3rd nursing diagnosis is always Knowledge Deficit.
c. Write full nursing diagnoses statements.
Example: Ineffective airway clearance R/T increased sputum production as evidenced by ineffective cough and coarse rhonchi.
Note: if nursing diagnosis is “Risk for” there is no evidence to report.
d. Include client’s level on Maslow’s Hierarchy.
2. Outcomes:
a. Include Nursing Outcome Classification (NOC).
b. State (2) STGs and (1) LTG.
c. Goals must be client-centered, specific, measurable, realistic, and have a time frame for achievement.
Examples: STG: Lungs will be clear in 8 hours. LTG: Client will demonstrate colostomy care by time of D/C.
Note: Sometimes it is more appropriate for LTGs to extend beyond D/C.
3. Interventions:
a. Include Nursing Intervention Classification (NIC).
b. Prioritize interventions in order of performance.
c. Must be individualized/specific/with frequencies/and be directly related to goals.
d. Cite work for all interventions
Example: 1. Observe/assess resp status for rate, depth, and chest wall movement Q4 hrs and PRN (Lemone & Burke, 2004)
4. Rationales: Specific to each intervention listed and scientific.
Example: 1. Tachypnea, shallow resp, and asymmetric chest movement may be indicative of resp compromise (Lemone & Burke, 2004).
Note: Use nursing textbooks and scholarly journals only.
No medical dictionaries or health-related internet web sites are to be used.
Cite work for all rationales.
Note: Last page of NCP must include APA formatted reference page for all works cited in interventions and rationales.
5. Documentation: Document your interventions as you would in written nurses’ notes. Example: 0800 RR shallow at 24/min, even, non-labored.
6. Evaluation: Evaluate each STG as met, partially met, or not met and care plan status as D/C, continue, or revise.
Example: Goal not met. Revise care plan. Note for teaching care plan: In order for learning to have taken place, the client must verbalize or demonstrate something.
Example: Verbalized how to read labels on canned goods for sodium content.
NURSING
DIAGNOSIS STATEMENT |
OUTCOMES
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INTERVENTIONS
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RATIONALES | DOCUMENTATION
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EVALUATION |
NOC: | NIC:
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Maslow’s Hierarchy Level:
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NURSING
DIAGNOSIS STATEMENT |
OUTCOMES
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INTERVENTIONS
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RATIONALES | DOCUMENTATION
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EVALUATION |
NOC: | NIC:
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Maslow’s Hierarchy Level:
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NURSING
DIAGNOSIS STATEMENT |
OUTCOMES
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INTERVENTIONS
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RATIONALES | DOCUMENTATION
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EVALUATION |
NOC: | NIC:
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Maslow’s Hierarchy Level:
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