CUYAHOGA COMMUNITY COLLEGE

Department of Nursing Education

MINI NURSING CARE PLAN

Student’s Name: Michael Kinder________________________________________

GENERAL INFORMATION

Patient Initials __________ Date of Care __________

Source of Data:

1) __________ Patient 2) __________ Chart 3) ________________ Family Member

4) __________ Health Care Team 5) __________ Other

Age __________ Sex __________ Martial Status __________ Admission Date _________

Religion ____________________

Advanced Directives (Durable Power of Attorney for Health Care, Living Will, etc): __________

Reason for Admission:

1. Primary Medical Diagnosis

2. Secondary Medical Diagnoses

3. Surgical procedures and dates

4. Definition of medical diagnoses: Reported signs & symptoms

(Use patient’s own words)

5. S/s diagnoses as given in your textbook

6. Brief description of basic pathophysiology of presenting condition(s)

MEDICATIONS AND TREATMENTS:

Nursing Diagnosis:

Assessment (S&O Data collected) Goals Interventions with Rationale Evaluation with supporting

observations.

Michael Kinder

Nursing Diagnosis:

Assessment (S&O Data collected) Goals Interventions with Rationale Evaluation with supporting

observations.

Michael Kinder

Concept Map Care Plan for

Initials, age, gender

Nursing Interventions (5):

Teaching needs & discharge planning: Outcomes (measurable, specific, include timeframe)

STG:

LTG:

Medical Diagnosis:

Assessment data, lab & dx tests: Medications (name, dose, frequency, indication)

Secondary Diagnoses:

Priority Nursing Diagnosis:

related to

as evidenced by

Evaluation of Outcomes:

Submitted by Michael Kinder on (date)

Lab and Test Data

LABORATORY STUDIES Latest Values/Date Laboratory Norms Explain Abnormals

CBC RBC

Hgb 12-18

Hct 35-52

WBC 3.7-11

Differential

Neutrophils 1.45-7.5

Eosinophils 0-0.45

Basophils 0-0.1

Lymphocytes 1-4

Monocytes 0-0.86

Platelets 150-400

Chemistry Na 135-146

K 3.5-5

Cl 98-110

CO2 23-32

BUN 10-25

Glucose 65-100

Creatinine 0.7-1.4

Calcium 8.5-10.5

Total protein 6-8.4

Albumin 3.5-5

Mg 1.7-2.6

Ph 2.4-4.5

ABG’s pH

pO2

pCO2

HCO3

Urinalysis Specific gravity 1,005-1,030

pH 5-8

Protein 0

Acetone 0

Other:

Coagulation

PT 8.4-13

PTT 23-32.4

INR 0.8-1.2

Culture and Sensitivity

X-ray/ Diagnostic Tests (date, test, abnormal results):

Michael Kinder

N1450 Head to Toe Assessment

Patient Name: Code status: Allergies:

Diagnosis:

PMH:

Surgical hx:

Weight:

Vital signs: Pain: Location:

Neuro:

Alert Person Speech: Garbled

Clear

Drowsy Place Aphasic

Slurred

Cough/gag Time

Sedated

Cardiac/Vascular:

Heart sound: Regular/ Irregular

Color: Normal Jaundiced Pale Other_______

Temperature/Moisture: Warm Dry Hot Cool Mottled Clammy Diaphoretic

Pulses:

Edema: None Pitting Non Pitting Generalized RA LA LL RL Other

Respiratory:

Sounds: Clear Rhonchi Crackles Wheezes

Assessment: Labored Unlabored Dyspnea Orthopnea Symmetrical SOB on exertion Shallow

Cough: Productive Nonproductive Weak/Strong Sputum: (Description)

GI:

Bowel Sounds: Present Hypoactive Hyperactive Absent

ABD: Contour of abd: Round Flat Obtunded

Soft Firm Tender Non tender

Stool: (Description)

Tubes/Drains:

Michael Kinder

N1450 Head to Toe Assessment

GU:

Content incontinent

Device: Foley Color: Clear/Cloudy

Skin: Intact Breakdown :( Location) Stage Other:

Surgical wound (location and description)

Needs: Independent assist complete care

Safety:

ID Band Allergy Band Call light within reach

Precautions: Universal Isolation (Description)

Lab Values:

HGB Na Cl BUN

WBC HCT PLTS Glucose

K Co2 Cr

Reason for being Abnormal:

Medications (Brand/generic name/ action/precautions)

SBAR/Narrative Note

Michael Kinder

S

Room: Name: Age:

DOA:

Activity: From:

Physician:

Consults

Diagnosis: Chief Complaint: Code Status:

B History Isolation: Fall Risk:

Bed Alarm:

Allergies:

A

VS q4 q8 ____ Neuro: A&Ox Respiratory:

O2:

BGM:

Cardiac:

Telemetry:

GI:

Diet:

TF

GU:

Foley:

Other:

Upcoming Tests: Labs: Na___ Mag__ Cl____ BUN___ Glu___ K___ Ca____ CO2____ Phos___

WBC_______ Hgb____ Hct____ Plts_____ _________ _________ ________

PT________PTT_______INR_________ ________ ___________ ________

R

Test/Treatment: Teaching Plan: Goals: Discharge Plans:

Notes:

S

Room: Name: Age:

DOA:

Activity: From:

Physician:

Consults

Diagnosis: Chief Complaint: Code Status:

B History Isolation: Fall Risk:

Bed Alarm:

Allergies:

A

VS q4 q8 ____ Neuro: A&Ox Respiratory:

O2:

BGM:

Cardiac:

Telemetry:

GI:

Diet:

TF

GU:

Foley:

Other:

Upcoming Tests: Labs: Na___ Mag__ Cl____ BUN___ Glu___ K___ Ca____ CO2____ Phos___

WBC_______ Hgb____ Hct____ Plts_____ _________ _________ ________

PT________PTT_______INR_________ ________ ___________ ________

R

Test/Treatment: Teaching Plan: Goals: Discharge Plans:

Notes:

Michael Kinder

Michael Kinder

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' NURS 1450 HEAD TO TOE ASSESSNIENT

Yital Signs 1f: Pulse:. _ __.--'Respiratory Rate:. __ """"'~P: ___ Pain: ___ Scale:. __ _

Neuro

. ~OC: a Awake CJ l~thatgic 0 obtunded a c~~'a Comments: i Qrientatiort: 0 person D. place a time Comment : t: · S~eech: ~· clear 0 ~lur:ed a nonverbal Com me s: \l qonversatiOn: Cl appropriate · 0 confused 0 nonver al Comments: · ~~ce: a symmetrical CJ droop to'_. side Comments: ,f Pfpils: right ~ 0 reactive Cl nonreactive left CJ reactive 0 nonreactive

r:/' I ~usctdQsl<s!etal ! • Grading: right arm left arm __ right leg_· _left leg_._ 1

t M'Obility: 0 bedrest 0 gait steady 0 gait unsteady 0 no movement to side ' ;!

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\:. · v scular [, , : CJ no . 0 yes:_·_ Carotid: 0 bruit 0 thrill Calf size: R __ L. __

\

:··.·. P '· es: radial brachial dorsalis pedal Comments: H!art: a Sl.and 82 Q Regular a irregular 0 83 Q 84 CJ murmur:----

\ Edema: D no Oyes: Homan's sign: a negative Cl positive __ _ S~in Color: CJ skin tone D pale CJ ruddy D rubor CJ Cyanosis. ____ _

· Homan's Sign: 0 negative CJ positive_. _side Turgor: 0 poor CJ fait .CJ brisk SdJera: 0 white CJ red 0 jaundice Q other:..:...·-=----:-----------

----... AY Fistula: fJNA Location: 0 bruit 0 thrill

1 R~$piratory · i Pa~ern: 0 Regular 0 Other: . Depth: Q Deep Q. Moderate 0 Shallow

Adpessory Muscles: Q No 0 Yes -Pulse Ox:·---Oxygen level:.:...:· --------: Lupgs: Q Clear: CJ Crackles: 0 rhonchi .in the bronchi : il [J. wheezes: · 0 diminished: 0 friction rub i Cohgh: CJ none Cl dry Cl moist, nonproductive t:l productive: --------:-J ,, Chfst Tube: 0 no 0 yes: settings: · drainage:, _______ _

t) 'Abttomen · . . v ..) · Shd,pe: D flat 0 sunken 0 round Q distended 0 ascites Comments~-_....;._ __ _

Bofel sounds: RLQ: RUQ: LUQ: LLQ: Pai~: (J no fJ yes: Cl :Vith palpation Cl without:._. ---------:,__ Va5cular: Q no a bruit: CJ thrdl: ---------J-Palbation: 0 soft 0 firm CJ rebound tenderness: . · . NGjTube: 0 No Cl Yes:-. nare: _Nare # CJ clamped CJ suction_.::_ drainage:. ____ _ Fee~ngtube:O No 0 yes: OPEG 0 small bor~ . nare # .· Tu& Feed: CJ No 0 Yes: · restdural: . · Ost~my: D no . 0 yes: location stoma: drainage:. ___ __ ! Sto4l: 0 none seen: last BM CJ Yes 0 FMS/tube: ______ _ 'Urit\).e: Cl none seen 0 yes: color turbidity Cl foley:------

1 Cl suprapubic a BRP 0 anuric: dialysis access-----------.---­

I.

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Michael Kinder

Drains/ Access a JP: Dr~age: Amount: color:

. ~ JP: -----------Drainage: Amount: ----color: ______ _

! HV AC: Drainage: Amount: color: ----~---

•' HVAC: Drainage: Amount: color:------q Wound Vac: Drainage: Settings: ______ ....._.

qoili~: __________ ~-~-------------------------; Ijtegumentary : ~·I aden Scale:. . . Strategies: CJ air mattress

1 CJ turn schedule CJ Other:---------------------no skin breakdown Cl macerated: _· ______ CJ excoriated: --------

.. ecchymosis: · · . · : ~ Steri strips: #:_Description: : . Steristrips: . #:_Description: ________________ _

: Staples: ·#; Description:-------~---------. q Staples: #; Description: :......· ---------------...,... d Sutures: #: Description: -------------------: q Sutures: #: Description: _______ ___: ________ _

; q Dressing: Description:-----------------\. g Dressing: Description: , q Dressing: Description:-----------------. S~ge 1: Measurement: · Tx: S~age 1: Measurement:----..,....-- Tx:. _ __._ ________ _ S~age 2: · · Measurement: Tx:_......_ _______ _

. S~age 2: Measurement: Tx: · Sdage 3: MeaSurement: Tx: -------------Sl'age 3: Measurement: Tx.:

. S .age 4: Measurement: Tx: -----------, I .---.:..----' S ,age 4: Measurement: Tx: ..... _________ __,.... : E' char: Measurement: · Tx: ------------: E

1

cliar: Measurement: Tx: -----------

CJ specialty bed CJ barrier cream

: D I: Measurement: Tx: -----------, . D: I: Measurement: Tz: ------------:-

I i.·

• Ebuipmentfinteuentions . , TED hose· Cl SCD's CJ C-collar Cl seizure precautions t:l isolation:--'------ortho: ___________ ___, _____ __, ___ ..._ _______ _

____ ..__. _____ .Signature: ------------'Date: ___ _

Michael Kinder

··~· .... '.

I. dommunity Services

I Use of services: CJ no Q meals on wheels CJ horrie health· CJ private caregiver CJ transportation: -------- CJ hospice: CJ other: ----------

Developmental Care Regyisites ~age: D intrauterine . CJ neonatal D infancy D childhood D adolescence · \ . D young adulthood CJ adulthood CJ pregnancy ~elation~hips: . D single .. CJ married CJ partner CJ divorced CJ widowed qccupatton: . a unemployed . a disability CJ retired qh.ildhood illnesses: ~:--':-·· :---:----------.-.....--...,.;.....--,_..----._-Perception of current life situation: _;,...._ _____ _:__.._..,._....;.... ______ _

. Health Deyiation Requisites _ l · Medical History . . 1'/euro: D stroke a TIA Q MS a Parkinson's . Q ALS a seizures a dementia I CJ Alzheimer's Cl dementia 0 headaches a pain syndrome:-------

' P~ychiatric: CJ schizophrenia · CJ manic depression D depression Cl other: -----1 $ENT: D cataracts 0 glaucoma · D sinus issues Cl other: ----..,.....~· --~---!! qardiovascular: .Cl CAD a heart failure a myocardial infarction.· D high cholesterol : i a hypertension Cl arrhythmias a angina D PVD a DVT D varicose veins

I j ~espiratory: a COPD CJ asthma a Tb a pneumonia Cl PE . Cl sleep apnea li qi: D bleeding a hemorrhoids D colostomy Cl ulcers Cl cirrhosis CJ gallstones Iii QU: CJ renal failure 1:1 prostate issues D urostomy Cl catheter .. D UTI Cl kidney stones

· ) areast: D pain 0 discharge · Cl cysts CJ mass CJ cancer Cl mastectomy: -----.Musculoskeletal: CJ arthritis 0 joint replacements: 0 injuries:------

!' · Endocrine: 0 diabetes .. 0 thyroid CJ other:·-....:.·-------------'-----·/! Jiematopoietic: CJ anemia D bleeding disorders: ·. · . . . .

1 i . l· D cancer: ·· · . Chemotherapy: 0 no a yes Radiation:. CJ no D yes

I i!! irttegumentary: Cl psoriasis CJ wounds: 0 other: .

Fbmales only: a LMP:. . . Cl postmenopausal CJ irregular .bleeding D pain CJ discharge II I Pregnant: CJ no CJ yes (due): . Lactating: a no r:l yes

I

ll, IMections: Cl C-Diff a MRSA Cl VRE a ESBL a other: __ ,...,..._..---------­Implanted J.Wdical devices: CJ no Cl pain pump Cl medication port CJ pacemaker or IC.D

1' T · CJ dialysis port · CJ dialysis fistula or graft CJ insulin pump C other: . . ll • Immunizations: Cl immunizations appropriate and according to schedule for age/development · I:.

1

.Issues/reactions to immunizations: ------------.,..· .,...;.--'----'--_,.....----l. Pneumonia vaccine: t:l no IJ yes, date: CJ urtknown

Influenza vaccine: 0 no Cl yes, date: HlNl: t:l no Cl yes, date: __ _ P@st Surgical History: 0 no CJ yes:_· _ _:_ ____ ..;..__ __________ _ i Issues with anesthesia: Cl no CJ unknown 0 yes: __ ......;. ________ _

Home Medications Medication Name Dose Frequency Reason Last dose

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Michael Kinder

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I . . Air I . -

TGbacco use: 0 no 0 yes, amount how long ear quit Dna EJviroilmental exposure to smoke toxins: D no 0 yes

I I Food/Water ____ ......__......_ ____ __.___

.SBecial Diet: D no D yes Unplanned wt gain/loss: D no D yes, amt_ jis~ues: D difficulty chewing D difficulty swallowing D nausea · D vomiting 0 anorexia· i Cl heart burn D other: ln ntition: Down teeth D ch:-ip-p-ed-:--te-e-=-th--::D=-=-lo_o_s_e-te-et-=-b--=0=-· -no-te~et-=-h-----....---

1 1 Dentures: CJ uppers Cllowers 0 full perception of fit:---------­JD!tary practices/restrictions due to religion or cul.ture: Cl no Cl yes i · . Elimination · . IF

1 quencyofBM: . . Characteristics: DateoflastBM: ____ _

i Isf!es: Cl constipation D incontinence D diarrhea Laxative use: Cl no 0 yes /Utinary patterns: D no issues 0 dysuria . 0 frequency 0 urgency 0 hesitancy-.----! I 0 anuric 0 incontinence (when): __ -:------=-:-"'"'--:-:-":---:--~----:---:'--.·ID~alysis: D no 0 peritoneal dialysis (frequency)_..,... __ D hemodialysis (frequency)_·_ ' I Activity and Rest :Changes in functional abilities: Cl no CJ yes .-;.··---:----:---=:------~----__,.--. Ahiputations: 0 no D y.es __ __prosthesis: D no · .0 yes-------T~ical exercise: how often: leisure activities:_. =-----;Ttpical #hour of sleep:----- issues falling asleep: 0 no Dyes Naps: 0 no 0 yes_ Able to stay asleep: Cl nci; 0 yes Do you feel rested upon awa.I<:erting: Cl no 0 yes ·

I . . . .

\\jhat do you do to help you fall/stay asleep: · . · .· . . 0 na 1 . . Solitude/Social Interaction ·

Religion: . Would you like to see a member of your church? Ono 0 yes---Ate there cultural or religious practices that are important to you that may have an impact on · y~ur hospitalizations: t:J no t:l yes----------..,...-..-----~~-----: Dp you have a.strong·re~is,io?s o~ moral objec~ion ~at would cause you to absolutely refuse a

· blood transfusion, even tf tt ts a hfe or death sttuatlon? D no t:J yes · . .· . ' om is your greatest support? What roles do you serve 111 your life? .

. Hazards A!re you in a relationship in which another person tries to control you? r:J no CJ Yes

I . you feel safe at home? t:l yes CJ no · . · g use? [J no t:J yes: type(s) · how often last use.__;__.-;.,..._._

~cobol use? Cl no r:J yes: type(s) how often •· last use ___ _ I · C: Have you ever felt the need to _gut down on your drinldng? ·. t:J no CJ yes I A: Have you ever been Annoyed by criticism about your drinking? t:J rto . Cl yes 1 G: Have you ever felt guilty about your drinking? 0 no 0 yes ! E: Have you ever had the need for an ~e opener to ease a hangover or as a nerve

·steadier? Cl no 0 yes ·

Michael Kinder

·--··';.

j: I

NURsiNG DATABASE ACCORDING TO OBEM·

------.-----.:Birthdate: ____ Age: __ · Ht:_,__ __ Wt:, ___ _

_ ,__ ___ .,......;. __ Source of data collection: ___ ___.._--'-------~

, :nergies and Reactions: ..,.... -.---------~....,......;---------------' ! rception ofCurrent Health (in patient's own words):_.,...... _______ ----' __ ...,...;

ason for Seeking Care: . ..,.·· . ._;,-..:....o...; _________ ..,....,..._,__.._ _______ _

U'ving Arrangements: CJ home .Cl apartment D assisted living . D long tenn care facility Facility: . D Live alone Cl Live with family Does anyone depend on you for care at home? D no D yes __,..~~---....---Is you need help at home; is there someone available to assist you? D no Cl yes·

:dvance Directives · Durable Power of Attorney for Health care? Cl no Cl Yes_~-=----=~----~-­Living Will? CJ no Cl yes Do Not Resuscitate? Cl DNR CC Cl DNR CC Arrest Declaration ofMental Health Treatment? CJ no CJ yes Organ Donor? CJ no CJyes

E1

• vironmental Barriers Stairs: CJno CJ yes: Number Location(s):. ____ --:--:--------'-----":-Stairs required to restroom? [J no Cl yes· number· __ _,provisions·

i Fhnctional Assessment ------, AIJCTIVITY : 1jransportation

~ g~ting , T . Tpileting

B:~thing

· Dlressing

, ~' alking r !

i BPmemaking !

'

S airs

iT ansfer !

PREADMISSION NEEDS r:J Independent r:J Dependent r:J Independent Cl Dependent r:J Independent r:J Dependent r:J Independent r:J Dependent r:J Independent 0 Dependent r:J Independent r:J Dependent · 0 Independent 0 Dependent 0 Independent Cl Dependent D Independent r:J Dependent

NEW ONSET DYes

r:JYes

DYes

DYes·

DYes

ClYes

ClYes ·

ClYes

I:JYes

Michael Kinder

' - . I ·~ \ \, .

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i I Normalcy

durrent Pain level: Location: acceptable level of pain I - ·.---------- '---

A[cute: r:J no r:J yes (onset) Chronic: Cl no r:J yes (onset)_...__--'--Quality (description) Cl constant D intermittent What aggravates your pain? ~'hat helps alleviate your pa~in-7---------------------

Has stress affected your sleeping? D no CJ yes Has stress affected your appetite? r:J no D yes t .

Has stress caused you to have: I · Decrease in pleasure or loss of interest in activities 1 Caused you to feel sad most of the time I History of depression I Interference with daily activities i Thoughts of suicide

0 no CJ.no Cl no Cl no Cl no

[J yes [J yes CJ yes · [J yes [J yes

1 Attempt at suicide? CJ no r:J yes when. ______ --' how __ --:=:----=--

1, Sense of loss or feelings of hopelessness r:J no D yes f{earing impairment: Cl no D yes hearing aid: D right D left Cl both '1isual impairment: r:J no r:J yes:r:J nearsighted r:J farsighted Cl both r:J .glasses r:J contacts

I i

Additional Informatio"n obtained from patient: I i,

I

1dmission Notes: .

I . i '! I

Michael Kinder

CUYAHOGA COMMUNITY COLLEGE

DIVISION OF NURSING

WEEKLY ANECDOTAL NOTE NURS 1600

Student: .,._.;;..;,;..;.;..;.;;..~,....,..;...,_.,..,..,.._ Qa.te: .. :"" ~---·· # Patients: _____ Instructor:

Weekly Anecdotal Note s u Nl Preoaratjon: Brings written materials as directed Answers questions correctly (hx, dx, rx1 labs, meds) and · relates them to this patlent(s) . Defines the medical dfaJZnosls/surgery '

Assessment: Collects patient dctll (including pt diagno.sis, medications. and labs) from appropriate sources in order to be prepared to administer nursing care ·

Performs head to toe assessment in organize~ fashion and recognizes normal/abnormal findings Performs ongoing assessments during care Recognizes changes throughout the shift Documents assessments in an appropriate manner Analysis Identifies nursing diagnosis/patient issues or problems Supports these identified problems with actual data Is able to prioritize nursing diagnosis and interventions Planning Identifies goals for the patient/day Goals are realistic, measurable, and patient focused List appropriate nursing interventions with rationale lmQlementation Performs psychomotor skills 1afely* Looks up skill prior to Implementing them. Is able to verbalize correct way to perform skill prior to implementation ' Maintain clean patient unit Organizes care to be completed in the prescribed time Adapts nursing care to meet unexpected needs E1<hibi~c<Uln·g:b:ehavion -· · •·

... ., ....

Evaluation

' E,vlciel}~e ~f ~oaJ attainment 0( U(I~I:ICC.eSS~UI goal iSSUeS

suggest d-ia'nges in the plan to meet goals · · ~ommunl~etiQ!J

·· ~flarreffifct:lve1y·and·ih nlmelymanner-· · Reports patient information to primary care provider S~ug~nt Re~I2QQ~Ibllltle~ Maintain patient safety* Responsible and accountable for nursing interventions and

.. -cate and.tn'elr results Correctly relates patient symptoms, lab values, etc. to their

. ·-condl.tlon . · Pr~fess\'onal appe:arai;ce ar'l:dbenavlorsand communications

~w~eJQy_Anecdota.t NP!E!.Revlsed lZ-2014 . I , ; ,. ',. ' .. ' . '•.' i: . I :' • ' : ·~ :' ~ .' , . ' ' :: ·

.... ~ ' ..

\

-------------------Comments/suggestions

Michael Kinder Elizabeth GennarelliS00613316

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