Fluent Essays

CARE PLAN ASSIGNMENT PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET Student Name: Week: Dates of Care: Patient Initials Sex Age Room Admitting Date Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Shortness of Breath, Chest pain Attending physician/Treatment team: Consults: Present Diagnosis: (Why patient is currently in the hospital) Arrhythmia/dysrhythmia (Heart failure) Atrial fibrillation with rapid ventricular response (HCC) ER Management: (if applicable) Allergies: Bactrim (Sulfamethoxazole trimethoprim) iodine rash Code Status: Full Isolation: (type and reason) None Admission Height: Admission Weight: Arm Band Location (colors & reasons) Communication needs: (verbal, nonverbal, barriers, languages) Verbal Past Medical History: (pertinent & how managed) Melanoma (HCC) Cancer COPD Genital herpes Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome) Tests/Treatments/Interventions impacting clinical day’s care (include current orders) Assessments and interventions: (Include all pertinent data) Vital signs: (2 sets per day) Time 0817 T 97 P 100 R 18 B/P 129/56 Time 1320 T 97.7 P 122 R 18 B/P 122/89 GI: Diet: Swallow precautions: Tube feedings: NG / G tube: Blood Glucose: (time & date) Last bowel movement: (time & date) Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting) Respiratory: 02 modalities: 02 Saturation: Suction: Resp Rx’s: Trach: Chest Tubes: Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Neurosensory: Neuro checks: Alert & Orientated: Yes Follows commands: Yes Speech Comprehensible: Yes Pertinent Labs/Test: Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) Cardiovascular: Telemetry: Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Musculoskeletal: Activity: Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps Renal: Catheter (indwelling/external): CBI: Dialysis: A/V access: Pertinent Labs/Test: Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O) Skin: Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type) Pain: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions) Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) Post-operative /procedural: Assessments/Interventions: (immediate post procedure care) Safety: Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient) Advance Directives/Ethical considerations: DPOA: Hospice: Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC RBC HGB HCT MCV MCH MCHC Platelets RDW MPV PT INR APTT Glucose BUN Creatinine Sodium Potassium Cloride Calcium T Protein Albumin SGOT SGPT Alk Phos Magnesium Amylase Lipase CPK LDH Cholestrol CK CK-MB Troponin I Myoglobin LDI Urinalysis Color Character Spec. Grav. pH Protein Glucose Acetone Bilirubin Blood Nitr Urobili RBC WBC Epithelium Urine Culture Chest X-ray MRI CT Scan Others test: Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics) Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient: Current overall plan of care: (A short statement that summarizes the anticipated plan of care) Discharge plans and needs: Teaching needs:(Disease process, medications, safety, style, barriers) Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format. ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article. List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis. Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority) 1 2 3 4 5 Medications Classification Dose Route Freq Purpose/Mechanism of Action Significant Side Effects / Adverse Reactions Nursing Implications Nursing Diagnosis: Identify the top two nursing Diagnoses and expand Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s) Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes) Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set) Nursing Diagnosis: Identify the top two nursing Diagnoses and expand Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s) Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes) Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set) PAGE 1 Rubric Name: Care Plan Rubric This table lists criteria and criteria group names in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. You can give feedback on each criterion by tabbing to the add feedback buttons in the table.Criteria Good 4 points 1. Patient information and health assessment: Complete patient demographics, health assessment and interventions All of the demographic section is completed, all areas of the health assessment is completed interventions are identified for the health assessment data that is identified. 2. Pertinent Diagnostic Data: Identify abnormal diagnostics, state significance for this patient. Identified all of the abnormal diagnostics and stated the significance for this patient.  3. Number of Nursing Diagnoses: Provided 5 correct nursing diagnoses for the patient based on the patient health assessment, history, labs, and pathophysiology. Identified 5 nursing diagnoses for the patient that are correct based on the patient assessment, history and data 4. Pathophysiology: Disease process description including “Signs and Symptoms” as well as APA references cited Explanation of pathophysiology chosen; given with accurate details related to client’s symptoms and current illness. APA references noted 5. Pharmacology: Complete and accurate description of current medication list that includes description of medications, side effects as well as nursing considerations specific to the patient List all MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug 6. Nursing Diagnosis: (Includes all 5 Dx) Reflects the primary diagnosis and is appropriate for patient scenario as well as priority level. Expressed in acceptable NANDA format. Also includes all parts stem, R/T, and AEB Diagnosis is appropriate for patient/priority level. NANDA approved. Diagnosis also includes all parts and information 7. Assessment: Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx 8. Patient Outcomes Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria 9. Interventions: Include interventions or nursing actions that directly relate to the patient's goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal Intervention portion contains an adequate number of interventions to help the patient/family meet their goal. The interventions are specific in action and frequency, and are also listed with rationales.  10. Evaluation: Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If is not met or partially met, plan of care is revised or continued and a new evaluation date Evaluation portion does contain data that is listed as criteria within the goal statement. Does describe the outcome as met, partially met, or not met, includes revision of plan of care, or new evaluation date/time.