NURSING DIAGNOSIS CARE PLAN

School of Nursing Name: Date:

Care Plan

Nursing Care Plan- Basic Conditioning Factors  
Patient identifiers:

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Age: Gender: Ht: Wt. Code Status:

Isolation:

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

 

 

Health Status  
Date of admission:

Activity level: Diet:

Fall risk (indicate reason):

 

Client’s description of health status:

 

 

 

Allergies: (include type of reaction)

 

 

 

Reason for admission:

 

 

 

 

 

Past medical history that relates to admission:

Socio-cultural Orientation  
Religious, Cultural and Ethnic background with current practices:

 

Socialization:

 

Family system (support system):

 

Spiritual:

 

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

 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       

 

 

 

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):

 

 

 

.

  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         BUN        
RBC         Cr        
HGB         GFR        
HCT         Na        
PLATLETS         K        
Diff:         CO2        
Polys         Ca        
Bands         Phos        
Lymph         Amylase        
Mono         Lipase        
Eosin         Uric Acid        
GBC indices         Protein        
MCV         Albumin        
MCH         Cl        
MCHC         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         Gast occult      
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. 2. 3.

Accu-check

1. 2. 3. 4.

Output:

 

Cardiovascular Assessment

Specialty devices:

 

 

 

Teaching needs:

Heart Sounds:

 

 

Skin Temp/Moisture/Color:

 

 

Edema: 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:

 

 

 

Condition of skin:

Nutritional Assessment:

 

 

 

 

Teaching needs:

Diet:

 

Eating patterns:

 

Insulin administration:

 

 

Treatment of hypoglycemia:

 

 

 

Alternative feeding patterns:

IV Therapy

IV fluids infusing:

 

Rate:

Tubing dated?

 

IV Site Assessment: Location

 

Date of insertion: Change (site or dressing)

 

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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