Nursing care plan

  TOURO COLLEGE

NYSCAS NURSING PROGRAM

(212) 463-0400 ext. 55261

 

 

Nursing Care Plan

 

 

 

Student Name: _____________________ Date: ____________________

Clinical Group/Instructor: _________________

 

ADMISSION DATA:

Patient initials_____ Admission date__________

Reason for hospitalization and initial evaluations: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Admitting Diagnoses: Primary and Secondary (if applicable) ____________________________________________________________________________________________________________

 

Major/Common signs and symptoms of admitting diagnosis : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PSYCHOSOCIAL HISTORY:

Write a brief narrative style history including age, gender, race/ethnic group, religion, family structure in childhood and as an adult, marital status, current significant relationships, education attained, current or last employment, living arrangements, environmental stressors in community, and legal issues if applicable.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

MENTAL STATUS EXAM

General Appearance and Motor Behavior: Describe hygiene, grooming, appropriate dress, eye contact, use of personal space, any unusual movements or mannerisms, speech ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Attitude toward interviewer:

Cooperative________ Uncooperative__________ Describe: ____________________________________________________________________________________________________________

Mood:

Happy___ Euphoric___ Sad___ Depressed___ Angry___ Labile___

 

Sensorium and Intellectual Processes:

Oriented to person___ place____ time____ and current circumstances_____ if no describe

Judgment and Insight:

Judgment – does patient interpret environment and situation correctly and adapt behavior and decisions accordingly? Describe.

Insight- does patient understand true nature of his situation and his own part in it? Describe.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NURSING ASSESSMENT

Diagnostic tests: explain any abnormal results of diagnostic tests such as chest x-ray, EKG, cultures, urinalysis, drug screen. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

LABS/BLOOD LEVELS: (list appropriate lab data for patient’s diagnosis and treatment) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

REST & ACTIVITY:

Identify any musculoskeletal issues that interfere with posture or ability to walk or self-care.

Fall risk assessment rating________ Assistive measures needed____________

 

Identify any issues that interfere with ability to fall asleep, or sleep 6-8 hours undisturbed such as a medical condition, discomfort, pain, napping, disturbing thoughts, anxiety, fear, hallucinations, alcohol or substance use, or a sleep wake disorder. Are there any medications prescribed at HS (at bedtime)? Does patient require PRN for sleep? Identify assistance required for ADL on unit if applicable.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

OXYGENATION:

Describe any irregularities in respiration rate/rhythm, breath sounds, mucus membrane color, productive cough, use of oxygen.

History of smoking_______ how long? ______ amount per day

Describe any irregularities in physical exam findings ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

SAFETY:

Pain Scale ___________________

Describe any current pain ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pain medication administered? Yes___ No____ Name and dose, and effect_______

History of head injury or seizures? Incident ________ Age of patient_____

 

NUTRITION:

Height_____ Weight______ BMI______ Diet__________ Any foods restricted?

Problems chewing, swallowing Yes____ No____ Dentures____ Appetite: good____ fair___ poor____

Describe unusual beliefs about food or eating ____________________________________________________________________________________________________________

Any type of assistance required, (describe if applicable) ____________________________________________________________________________________________________________

Describe any IV or tube feeding (if applicable)

____________________________________________________________________________________________________________

Any recent weight loss/gain? (if applicable – estimate weight loss/gain and describe reason for weight loss/gain)

____________________________________________________________________________________________________________

SKIN INTEGRITY:

Describe skin color, turgor, rashes, bruises, recent wounds and wound care (if applicable)

____________________________________________________________________________________________________________

ELIMINATION:

Gastrointestinal System:

Describe any nausea or vomiting related to possible medication side effects or pregnancy?

Usual bowel pattern__________________ Last bowel movement____ consistency____ color____

Describe any diarrhea, constipation, flatus, incontinence or ostomy.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Urinary System:

Describe any problems: frequency, urgency, difficulty starting stream of urine, incontinence, hematuria

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS:

Complete medication form below and include psychiatric, non-psychiatric and over-the-counter products/herbal preparations.

NAME, DOSAGE, ROUTE: RATIONALE: ASSESSMENT/CONSIDERATIONS:
     
     
     
     
     
     
     
     
OTC MEDS/HERBALS:
List allergies and type of reaction:

 

 

NURSING DIAGNOSIS #1 include stem, related to, as evidenced by:

 

Predicted Behavioral Outcome: The patient will
 
Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1.   1.   1.  
2.   2.   2.  
3.   3.   3.  
Evaluation: Summarize patient progress toward outcomes. Refer to continued assessments needed. Note improvements and progress. Include responses to medication.

 

 

 

 

 

 

 

 

NURSING DIAGNOSIS #2 include stem, related to, as evidenced by:

 

 
 
Predicted Behavioral Outcome The patient will
 
Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1.   1.   1.  
2.   2.   2.  
3.   3.   3.  
Evaluation: Summarize patient progress toward outcomes objectives. Refer to continued assessments needed. Note improvements and progress. Include responses to medication.
 

 

 

 

 

 

NURSING DIAGNOSIS #3 include stem, related to, as evidenced by:

 

 
 
Predicted Behavioral Outcome The patient will
 
Nursing Strategies: Evidence based Rationale for Strategies: Patient’s Actual Responses (Evaluation):
1.   1.   1.  
2.   2.   2.  
3.   3.   3.  
Evaluation: Summarize patient progress toward outcomes objectives. Refer to continued assessments needed. Note improvements and progress. Include responses to medication.
 

 

 

    Revised by C.W & S.L on 4/26/2021
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