Cape Girardeau Career & Technology Center – School of Practical Nursing

Care Plan Packet – Steps to Follow

DATE__________ STUDENT’S NAME_______________________________ CLINICAL ROTATION_____________ INSTRUCTOR___________________________________

DIRECTIONS: This packet is to be completed prior to beginning care for each assigned patient. Follow these three steps in developing your plan of care.

Step #1 Data-Gathering

Gather information from the chart, the patient, the staff, etc. Fill out as much of the Data-Gathering Sheets as possible while at the hospital

o General Information o Social History o Health History BEFORE this Admission o Current Health Status (Assessment) o Admitting Diagnosis

Step #2 Research

Fill out the Research Sheets by looking up the following information:

o Disease Information o Diagnostic Tests (the instructor will determine how many, how recent, etc)

o Medication Information o Unknown Words o Patient Teaching

NOW…..USING A HIGHLIGHTER……..HIGHLIGHT ALL ABNORMALITIES, PROBLEMS, AND NEEDS

Step #3 Care Plan

From the highlighted abnormalities, problems, and needs, choose 2 priority needs and write a Nursing Diagnosis for each of the priority needs, with

“related to” and “as evidence by”.

Write a Patient/Family Goal and a Nursing Goal for each nursing diagnosis.

Answer the questions regarding each nursing diagnosis.

Write 3 Interventions with Rationale for each nursing diagnosis.

Write an Evaluation for each of the interventions at the end of each clinical day.

Update and revise your interventions as needed (for example, patient condition changes, new orders written, etc.)

Your clinical instructor will look at all of your paperwork at the beginning of each clinical day. Verbal and written suggestions and corrections will be given to improve your paperwork. You are strongly encouraged to implement these suggestions. DO NOT REWRITE ANY PORTION OF THE PAPERWORK UNLESS DIRECTED TO BY THE INSTRUCTOR On the last day of your clinical week, please turn in all your clinical paperwork in a pocket folder to your clinical instructor. The clinical instructor will review your completed paperwork, assign a grade of either ACCEPTABLE OR UNACCEPTABLE and then return the graded paperwork to you.

GENERAL INFORMATION

Patient’s Initials________ Sex: ____Male ___Female Age: _____ Race: _______ Height:_________ Weight:________ Admission Date:____________ Code Blue Status: ________

_____NKDA Allergies___________________________________________________________________________________________________________________________________________________________

Primary Physician____________________________ Counsultants____________________________________________________________________________________________________________________________

Reason for this Admission: ______________________________________________________________________________________________________________________________________________________________

Previous Hospitalizations and Surgeries (include dates if possible)_______________________________________________________________________________________________________________________________

SOCIAL HISTORY

Marital Status: M W D S Retired: Y N Occupation or Former Occupation if retired_______________________ Significant Others:___________________________________ Religion/Cultural Beliefs____________

Present Residence________________ Lives with:___________________ Ever Smoked? Y N Smokes _____ packs/day for ____ years Date quit smoking________ Drinks Alcohol Y N Number of drinks/day _______

HEALTH HISTORY BEFORE THIS ADMISSION

Activity Level: __________________________ Diet:____________________________ Elimination Patterns: Bowel __________________ Urinary ____________________

Any Diseases, Disorders, Problems, etc for the following body systems in Patient’s Past History? Mental/ Neurological/Sensory

Respiratory

Endocrine

Integumentary Gastrointestinal Musculoskeletal

Circulatory/Cardiovascular

Genitourinary Home Medications

DATA-GATHERING

DATA-GATHERING

CURRENT HEALTH STATUS (ASSESSMENT)

Date of Initial Assessment__________

Ongoing Assessment &/or Changes

Date: Ongoing Assessment &/or Changes

Date: Ongoing Assessment &/or Changes

Date:

Mental Status:

Alert Oriented x 4 Speech clear/appropriate Mood______________ Memory________________ Eye Contact_________ Attention span___________ Hygiene____________ Handgrips_______________

Sensory: Eyes:

Ears:

Nose:

Other:

Pupils equal round reactive Size: _____mm No redness or drainage Vision: Good, no glasses Good with glasses Hearing: Good, no device Good with device No congestion/blockage Smell: Intact Taste: Intact Sensation: Numbness/tingling Detects tactile stimuli

Oral cavity:

Mucous membrane: Pink Moist Intact Tongue: Midline Teeth: Natural In good condition Bridge/Partial Dentures Fit well

Skin:

Warm Dry Pink/Natural Turgor good, no tenting Intact (no ulcers, incisions, abrasions, rashes)

Cardiovascular:

Apical pulse regular rate____ Telemetry_______________________ Peripheral pulse strong site____ Pedal pulses palpable/strong/equal Capillary refill < 3 seconds

Homan’s ______ Pedal edema_______

Respiratory:

Lung Sounds:____________________ Respirations: Even Unlabored Room air Oxygen___L/min per ___ Pulse oximetry_____%

Gastrointestinal: Appetite_________________ N/V Bowel Sounds___________________ Distention Incontinence Date of last BM______ Character of BM__________

CURRENT HEALTH STATUS (ASSESSMENT) continued

Ongoing Assessment &/or Changes

Date: Ongoing Assessment &/or Changes

Date: Ongoing Assessment &/or Changes

Date:

Genitourinary Color & character of urine_____________________ Dysuria Incontinence Date of LMP____ Vaginal discharge

Endocrine: Musculoskeletal:

Diabetic # or yrs_________ Most recent blood glucose:_________ Management____________________ Muscle tone__________ MAE

Equipment/devices

Foley NG PEG Drains _________________________ Chest tube______________________ Walker W/C Cane Other __________________________

Most recent VS & Pain assessment

BP_______P_______R_______T_____ Pain rating____ Location___________ Description______________________ Pain Management________________

Nutrition Current Diet:_____________________ 24 h intake_____24 h output________ IV solution______ rate_____site_____ Condition of site__________________

Activity orders Level of activity_____________________________ Limitations_________________________________

Other info:

PATIENT’S ADMITTING DIAGNOSIS (dx)____________________________________________________

What labs/tests/assessments were done to confirm admitting dx? What treatment is the patient getting for the admitting dx?

What labs/diagnostics/assessments confirm improvement or complications? Why is the patient still in the hospital?

DATA-GATHERING

DISEASE INFORMATION SHEET

This patient may have several diseases or medical disorders. Complete one Disease Information Sheet for the primary disease or disorder related to this hospitalization. You will want to research

the other diseases or medical disorders that this patient currently has or had had in the past, but you only need to fill out this sheet on the primary disease or disorder. If you have another assigned

patient with this same disease/disorder, you may use this Disease Information Sheet rather than filling out another one.

Disease or disorder

A textbook description of this disease/disorder Source of information:_____________________________________________________

Possible causes (etiology/pathophysiology)

Usual symptoms

Usual treatment/management

Possible nursing diagnosis

RESEARCH

DIAGNOSTIC TESTS (Labs, radiology, etc): List labs, radiology tests, and other diagnostic tests done on the patient as directed by your instructor.

Name of Test Date of Test Normal Values/Findings Patient’s Test Results How does this test relate to this patient? Nsg Assessment/Interventions Required

RESEARCH

MEDICATION INFORMATION: List all meds ordered for this patient. Do medication cards on the meds you are to administer during your clinical time.

Name of Medication Why is this patient receiving this med? Name of Medication Why is this patient receiving this med?

RESEARCH

UNKNOWN WORDS……..Write down unknown words as you read the patient chart and research information.

Using a dictionary, write the definitions for these words. Unknown Words Definitions

PATIENT TEACHING…….What teaching does this patient (or family) need prior to discharge? Diet

Wounds, Incisions, Dressings, etc.

Activity

Tubes, Equipment, etc

Medications

Other

RESEARCH

Reason for Admission and/or Medical Diagnosis

Nursing Diagnosis #1

______________________________________________related to __________________________________as evidenced by_______________________________________

What body system(s) will you thoroughly assess based on this nursing diagnosis?

What is the worst/most likely complication to anticipate based on this nursing diagnosis?

What will you need to monitor to identify this complication if it develops?

Patient/Family Goal or Expected Outcome Nursing Goal or Expected Outcome

Nursing Interventions Rationale Evaluation

1)

2)

3)

CARE PLAN

CARE

Reason for Admission and/or Medical Diagnosis

Nursing Diagnosis #2

______________________________________________related to __________________________________as evidenced by_______________________________________

What body system(s) will you thoroughly assess based on this nursing diagnosis?

What is the worst/most likely complication to anticipate based on this nursing diagnosis?

What will you need to monitor to identify this complication if it develops?

Patient/Family Goal or Expected Outcome Nursing Goal or Expected Outcome

Nursing Interventions Rationale Evaluation

1)

2)

3)

CARE PLAN