Care Plan 2

FYI info careplan is the only information we have for this careplan. oh the client was alert and  oriented.. she was very friendly

please filled in your own information

 

Client Code Name: D L

 

Client’s Age: os Gender: F

 

Present Medical Diagnoses: AFIB, HTN, hypothyroidism, chest Pressure

 

Present Surgery (if applicable): NO

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

 

Spiritual Well-Being:

 

Allergies: Alleres tetracy _____ Augmentin Code Status:

 

Vital Signs: T & 8 P 89. R 15 BP 120/80

 

SPO₂ A

__________________________________________________________________________________________________________

 

Fall Risk Assessment (include score): Pain assessment (include reassessment):

 

Time : 8am

 

Score :

 

Intervention :

 

Reassessment Time : 11am

 

Score : 0

 

Diagnostic Assessments-Important EKGs, X-Rays, and Labs

 

Lab/Other Test : WBC, RBC, HG?, HCF, PLATELET, MONOCYTE

 

Patient values : 5-2, 2-52, 39-6, 87-2, 186, 7-2

 

Inference

 

Medications Ordered for Client:

 

Medication and Dose with : Aspirin, Famotidin, nebivolol, enoxaparin

 

Generic Name of Drug : 81m, 40mg, 10mg, 100mg

 

Brand name : 9

 

Times of Administration

 

Indications of Drug

 

Adverse Effects

 

Nursing Implications

 

Treatments and Procedures : Pti Enoxaparin

 

Day & Times : 1 a day

 

Rationale : to treat blood clots

 

Nursing Interventions:

 

Assessment Findings : R

 

Diagnoses

 

Expected Outcomes

 

Nursing Interventions

 

Evaluation

 

Reflections of the day:

 

Edyth T. James Department of Nursing

Daily Clinical Log

 

Client Name: _____________________________

 

Client’s Age: _________ Gender: ________________

 

Present Medical Diagnoses: ____________________________________________________________________________

 

Present Surgery (if applicable): _____________________

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

__________________________________________________________________________________________________________________________________________________________________

Spiritual Well-Being: _________________________________________________________________________________

Allergies: __________________________ Code Status: _________________________

Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________

 

Physical Examination:

 

General Appearance:

 

Psychiatric:

 

HEENT:

 

Neck and Lymph Nodes:

 

Pulmonary:

 

Cardiovascular:

 

Skin and Nails:

 

Abdomen:

 

Genitourinary:

 

Pelvic and Rectal:

 

Extremities:

 

Musculoskeletal:

 

Neurological (DTR’s, reflex grading, cranial nerve evaluation):

 

Incisions:

 

Drains:

 

Diet/Nutrition:

 

IVs:

 

Intake and Output:

 

Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):

 

Pain assessment (include reassessment):

Time	Score	Intervention	Reassessment Time	Score

 

Diagnostic Assessments – Important EKGs, X-Rays, and Labs:

Lab/Other Test	Patient values	Inference

 

Medications Ordered for Client:

 

Medication and Dose with Brand name	Generic Name of Drug	Times of Administration	Indications of Drug	Adverse Effects	Nursing Implications

 

 

Treatment:

 

Treatments and Procedures	Day & Times	Rationale

 

 

 

Nursing Interventions:

 

Assessment Findings	Nursing Diagnoses	Expected Outcomes	Nursing Interventions	Evaluation

 

 

Reflections of the day:

 

 

 

 

 

Edyth T. James Department of Nursing

NURS 489 – Synthesis of Complex Nursing Care

Clinical Care Plan

 

 

 

Student: _________________________________ Date: ______________________________

 

Instructor: ______________________________ Clinical Course: ______________________

 

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

 

Date of Admission: ________________ Date of Care: _____________________________

 

Present Medical Diagnoses: ____________________________________________________

 

Present Surgery (if applicable): _____________________ Date of Surgery: ______________

 

Allergies: __________________________ Height: ________ Weight: _________

 

Code Status: ________________________

 

 

Section I

General Data

(Points 5)

 

Chief Complaint:

 

 

History of Present Illness (Detailed):

 

 

 

 

 

Past Medical/Surgical History:

 

 

 

Social History:

 

 

 

Family History of Illness:

 

 

Immunization History:

 

 

Description of Procedures (Surgeries) Performed this Admission:

 

 

 

Section II

Pathophysiology

(Points 10)

 

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan)

 

Definition:

 

Etiology:

 

Pathophysiology:

 

Signs & Symptoms:

 

Diagnostic test:

 

Treatment:

 

 

 

 

Section III

Assessment

(Points 20)

 

Physical Assessment:

 

General Appearance

 

 

Neurosensory

 

 

Psychosocial

 

 

Cardiovascular

 

 

Respiratory

 

 

Gastrointestinal

 

 

Genitourinary

 

 

Musculoskeletal

 

 

Integumentary

 

 

Incisions

 

 

Drains

 

 

Diet/Nutrition

 

 

IVs

 

 

Vital Signs

 

 

Intake and Output

 

Pain assessment (include reassessment)

 

 

Fall Risk Assessment (include score)

 

 

Pressure Ulcer Risk Assessment (include score)

 

 

 

 

 

Section IV

Diagnostic Data

(Points 10)

Diagnostic Tests	Patient’s value	Normal Range	Inference (why is this patients value abnormal)

 

Section V

Treatment and procedures

List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

(Points 10)

Interventions	Rationale

Section VI

Teaching and Health Promotion(Points 5)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

 

1)

 

2)

 

3)

 

4)

 

5)

 

Section VII (Points 5)

List of Nursing Diagnoses Use your assessment, the client’s medications, and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)

 

1)

 

2)

 

3)

 

4)

 

Section VIII (Points 10)

Medications

Medication Dose/ Brand/ Generic Name	Mechanism of Action/Indication for Use	Contraindication	Adverse Effects/Side Effects	Nursing Implications	Outcomes

 

 

Section IX

Nursing Interventions

(Points 15)

CAREPLAN FOR “3 ” (MINIMUM) NURSING DIAGNOSES

 

Assessment findings	Nursing Diagnosis (Actual & Potential Deficits, Wellness Diagnoses)	Outcomes Short and Long Term	Interventions/ Nursing Systems (Dependent & Independent)	Rationale (Why are performing that intervention?)	Evaluation/ Outcome (What was the actual result?)

 

 

 

 

 

School of Health Professions, Science and Wellness

Edyth T. James Department of Nursing

 

CLINICAL CARE PLAN GRADING CRITERIA

 

 

Course Number: ______________________________________

 

Name of Student: _____________________________________

 

Date:________________________________________________

 

 

Grading Criteria	Possible Points	Points Earned/Comments
SUBMISSION ON DUE DATE	5 Points
Section I General Data, Health History, and Review of Systems	10 Points
Section II Attached references in APA Format	5 Points
Pathophysiology of Disease Process	10 Points
Classic Signs and Symptoms of Disease Process	5 Points
Section III Physical Assessment	15 Points
Section IV Diagnostic Data	5 Points
Section V Treatments and Procedures	5 Points
Section VI Teaching and Health Promotion	5 Points
Section VII List of Nursing Diagnoses	10 Points
Section VIII Medications	5 Points
Section IX Care Plan with 4 minimum nursing diagnoses	20 Points
TOTAL POSSIBLE POINTS	100 Points

 

 

Name of Clinical Professor: ____________________________________________