Client Profile - Get as DOC by 48YM6JC2

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									         Nursing B26
         Clinic Forms

      3rd Semester RN


MEDICAL/SURGICAL ROTATION


    NURSING PROCESS
       CARE PLAN
        PACKET


     Clinical Site Instructor:



         RN STUDENT:
NURSING PROCESS GRADE SHEET                                        Student: _________________________

                Grading Criteria                     Possible   Points            Comments
                                                      Points    Earned
Part I:                                                 7
Face sheet and physicians orders
(2 points)
Physical assessment (5 points)
          Objective data covered all signs
          Subjective data covered all symptoms
      IV lines, catheters, chest tubes & NG
           tubes etc. are added to the appropriate
           system
Part II : Pathophysiology Concept Maps                 12
Work up 2: (4 points)
Definitions, etiology, chronicity, prognosis, risk
factors, signs and symptoms, lab and diagnostic
studies, medical and nursing interventions, and
potential complications.
Patient Specific (2 points)
References (2 points)
Inter-related (4 points)
Maximum 2 pages per map
Part III: Medications / Tactis                         12
     Client specific
     List of all medications
Part IV: Labs / Diagnostics                            15
         Client specific
         Anticipate MD Response
         Highlight abnormal values document
          possible causes
Part V: Plan of Care
Nursing Diagnosis (2. 5 points / Dx)                   10
         Covers bio-psycho-socio needs as
          related to the patient
         Nursing Diagnosis are prioritized
          appropriately
         Nursing Diagnosis are based on Nanda          2
          Format (complete)
         Nursing Diagnosis reflect defining
          characteristics
Goals (1 pt/goal)
         Patient specific
                                                        8
         Realistic and measurable
         States a time frame
         Relates to nursing diagnosis and nursing
          orders
Interventions and Rationales
         Appropriate                                  16
         Realistic
         Minimum of 4 per Dx
         Prioritized
         Sources cited
Evaluation                                             16
         Statement of met/unmet (2pt)
         Describe progress towards goals (2 pts)
         Evaluate effectiveness of nursing
          interventions (6 pts)
         List suggested revisions     (6 pts)
Level Outcome Summary Sheet ( 2 pts)                    2
Final Score
Please see comments throughout paper
                               PART I: DEMOGRAPHICS & CURRENT PHYSICIAN ORDERS

Room # /       Height        Weight   Age /        Immunization / Date       Advanced     Code Status      Admit   Date(s) of
 Initials                    (kgs)    Gender                                 Directive                     Date      Care
                                               □ Influenza                    □ Yes      □Full
                                                                                         □Directed
                                               □ Pneumovax                    □   No      □ CPR
                                                                                          □ Drugs
                                               □ Tetanus                                  □ Ventilator
                                                                                          □ Defibrillate
                                                                                         □DNR
Admitting Diagnosis



Secondary Diagnoses (Acquired during hospital stay, subsequent to admitting diagnosis)



History of present Illness (Sequence of events beginning from admission expanding to day of care)
Why did the client seek initial care? What happened as a result of the admission diagnosis? Is this still a concern for this
patient? Correlate problems with medication compliance




Recent Surgical Procedure(s) / Date(s) (Within in the past five years, or relevant to current diagnoses)




Past Medical History-
Correlate with home medication use and past surgeries




Substance Use (Include type, frequency, and duration)

Tobacco         □ Yes □ No

Alcohol        □ Yes □ No

Elicit drugs   □ Yes □ No

OTC            □ Yes □ No

Allergies / Reactions


Ethnicity               Religious Preference               Marital Status / Family Structure               Occupation
                  CURRENT PHYSICIAN ORDERS
ALL ORDERS THAT HAVE NOT BEEN DISCONTINUED ARE CURRENT ORDERS
Risk factors                                     PART II: PATHOPHYSIOLOGY CONCEPT MAP                                           Potential complications
                                                       Highlight patient specifics in each box

                                                               Signs and symptoms




                                             Disease Process _______________________________________
                                            Pathophysiology (Definition / etiology chronicity and prognosis)




      Medical interventions, labs and diagnostic studies                                                       Nursing interventions
                                  Interrelation
(write out the correlation between your patho’s. How does one relate to another)
                                     PART III: T A C T I S FACESHEET



Complete a medication list for ALL drugs, routine and PRN, which includes drug, dose and frequency.


□Review medication reconciliation form
□Which medications were taken at home prior to hospitalization?
Routine Medications

PO




IV-(how is it mixed ie. Base solution? What does the drugbook say to mix it in? Is it the same?)




Other (topical, inhalant etc)



PRN Medications (must include ALL PRN’s)

PO




IV




Other


IV insertion date:
IV location:
Tubing change date(s):
                                                            PART III: PRESCRIBED MEDICATIONS: T A C T I S


MEDICATIONS – TRADE / GENERIC________________________________________________________________________________________________

DOSE / ROUTE / FREQUENCY ______________________________________________________________________________________________________

PHARMACOLOGICAL CLASSIFICATION____________________________________________________________________________________________

Why is THIS client receiving this drug? __________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

Is this a home medication?            Yes      No
               T                  A                           C                         T                           I                                  S
  Therapeutic classification                Action            Contraindications          Toxic /Side Effects        Interventions                                   Safety
                                                                                        (Most serious & frequent)     (Include nsg intervention,           (Include MSI *& MSD*for all
                                                              (list only if
                                                                                                                    labs, parameters for this med)                   IV Meds)
                                                              contraindicated for
                                                              this client)
                                                                                                                                                       Safe dose: □Yes □ No
                                                                                                                                                       Crush med: □Yes □ No
                                                                                                                                                       For IV meds:
                                                                                                                                                           How is it mixed?
                                                                                                                                                           How fast can it be
                                                                                                                                                           administered?




*All meds being titrated (i.e., heparin) state appropriate lab results related to medication administration.                                         Allergies: _________________
** MSI – minimum safe infusion; MSD – minimum safe dilution                                                                                          Reference: ________________
                                             PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

    Test          Reference   Admit      Date    Date      Identify  / Significance / Trends(Explain)/ Nursing Interventions /Anticipated MD
                   Range      Date       Day 1   Day 2                                                                                 response
C                             Baseline
B   WBC
C
    RBCs

    Hgb

    Hct

    MCV

    MCH

    MCHC

    RDW

    Retic.

    Platelet

    Neutrophils
W
B   Lymphocytes
C
    Monocytes
D
i
    Eosinophils
f
f
    Basophils
                                                   PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

    ADMIT DATE _________ DATE OF CARE_______                CLIENT’S ROOM #_____             REFERENCE_____________________________
B
L   Test             Reference   Date       Date     Date     Identify  / Significance / Trends(Explain) / Nursing Interventions /Anticipated MD
O                     Range      Baseline                                                           response
O   Sodium
D
    Chloride
C
H
E   Potassium
M
I   CO2
S
T
R
    BUN
Y
    Creatinine

    Glucose

    Magnesium

    Calcium

    Phosphorus

    INR
C
O   PT
A
G
    PTT
    On anticoag. 
                                                    PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

    ADMIT DATE _________ DATE OF CARE_______                 CLIENT’S ROOM #_____             REFERENCE_____________________________

    Test              Reference   Date       Date     Date     Identify  / Significance / Trends(Explain) / Nursing Interventions /Anticipated MD
                       Range      Baseline                                                           response
    AST

    ALT

L   Acid
I   Phosphatase
V
E   Ammonia
R
    LDH
F
U
N   Alk. Phos.
C
T   Total Bilirubin
I
O
N   Cholesterol

    Uric acid

    Total protein

    Albumin

    Globulin

    Amylase

    Lipase
                                                         PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

     ADMIT DATE _________ DATE OF CARE_______                         CLIENT’S ROOM #_____     REFERENCE_____________________________

     Test                    Range            Date             Date               Date   Identify  / Significance / Trends / Nursing Interventions
                                              Baseline                                                    /Anticipated MD response

A    pH
B
G’   pCO2
S
     pO2

     BE

     O2 Sat

     HCO 3

     Interpretation
     *Oxygen            Device       Device               Device         Device
     (if not on vent)

                        % FiO2       % FiO2               % FiO2         % FiO2




     Action taken
     to correct
     balance?
                                                         PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
    ADMIT DATE _________ DATE OF CARE_______                      CLIENT’S ROOM #_____              REFERENCE_____________________________

    Test               Range       Date           Date     Date     Identify  / Significance / Trends / Nursing Interventions /Anticipated MD response
                                   Baseline

D   Digoxin
R
U   Theophylline l
G
    Dilantin
L
E   Antibiotics
V
E
L   Peak and
S   Trough
    Micro
    Blood, body
    fluids, swabs
    etc.




    Source:              Range          Date              Date       Identify  / Significance / Trends / Nursing Interventions /Anticipated MD response
                                       Baseline
    Color
    Appearance
    Spec.gravity
U   Protein
A
    Glucose
    Ketones
    Nitrites
    Leukoesterase
    Bacteria
    Blood
    Other
    How was Urine
    obtained? Cath,
    clean catch etc.
    Pt has catheter?     Y     N   Date inserted:
                                          PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

ADMIT DATE _________ DATE OF CARE_______            CLIENT’S ROOM #_____    REFERENCE_____________________________

Test           Body Part   Reason THIS test       Date             Date          Identify  / Significance / Trends / Nursing
               Involved     performed on          Result          Result           Interventions /Anticipated MD response
                             THIS client
X rays




X rays




X rays




MRI /
CT
(circle one)




Nuclear
Scan


Other
                                          PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL

ADMIT DATE _________ DATE OF CARE_______           CLIENT’S ROOM #_____             REFERENCE_____________________________


Test           Range    Date       Date     Date     Identify  / Significance / Trends / Nursing Interventions /Anticipated MD response
                        Baseline




                                                   Record of Intake and Output
                       INTAKE                                                                  OUTPUT
PO                                                           PO
IV                                                           Urine
IVPB                                                         Stool
NG                                                           Tubes,drains
Tube feeding                                                 Other
Other

Shift totals
                           PART V: NURSING DIAGNOSES: PRIORITIES AND RATIONALES

     NANDA Statement in Order of Priority                               Rationale for Priority
                                                      (Why did you put them in this order? Does your assessment
                                                                    correlate to these diagnoses?)
1.




2.




3.




4.
                                                                               PART V: PLAN OF CARE

Priority                  NANDA                                   Goals               Nursing Interventions        Rationale               Evaluation
#                    Diagnostic Statement                                               Level 3 focused
           NDx: (problem)                               (list measurable outcomes)   1.                       1.                      Goals accomplished?
                                                                                                                                   STG ?      □ Yes     □ No
                                                        LTG: Client will:
                                                                                                                                   LTG ?        □ Yes       □ No


                                                                                                                                         Progress to LTG?




                                                                                     2.                       2.
           R/T: (etiology / factor)
                                                        STG: Client will:                                                      Effectiveness of nursing interventions?




                                                                                     3.                       3.

           AEB: (s/sx; defining characteristics, lab,
                   diagnostic data)




                                                                                                                                        Suggested revisions?
                                                                                     4.                       4.
                                                                               PART V: PLAN OF CARE

Priority                  NANDA                                   Goals               Nursing Interventions        Rationale               Evaluation
#                    Diagnostic Statement
           NDx: (problem)                               (list measurable outcomes)   1.                       1.                      Goals accomplished?
                                                                                                                                   STG ?      □ Yes     □ No
                                                        LTG: Client will:
                                                                                                                                   LTG ?        □ Yes       □ No


                                                                                                                                         Progress to LTG?



                                                                                     2.                       2.

           R/T: (etiology / factor)
                                                        STG: Client will:                                                      Effectiveness of nursing interventions?




                                                                                     3.                       3.



           AEB: (s/sx; defining characteristics, lab,
                   diagnostic data)



                                                                                     4.                       4.

                                                                                                                                        Suggested revisions?
                                                                               PART V: PLAN OF CARE

Priority                  NANDA                                   Goals               Nursing Interventions        Rationale               Evaluation
#                    Diagnostic Statement
           NDx: (problem)                               (list measurable outcomes)   1.                       1.                      Goals accomplished?
                                                                                                                                   STG ?      □ Yes     □ No
                                                        LTG: Client will:
                                                                                                                                   LTG ?        □ Yes       □ No


                                                                                                                                         Progress to LTG?



                                                                                     2.                       2.

           R/T: (etiology / factor)
                                                        STG: Client will:                                                      Effectiveness of nursing interventions?




                                                                                     3.                       3.



           AEB: (s/sx; defining characteristics, lab,
                   diagnostic data)



                                                                                     4.                       4.

                                                                                                                                        Suggested revisions?
                                                                               PART V: PLAN OF CARE

Priority                  NANDA                                   Goals               Nursing Interventions        Rationale               Evaluation
#                    Diagnostic Statement
           NDx: (problem)                               (list measurable outcomes)   1.                       1.                      Goals accomplished?
                                                                                                                                   STG ?      □ Yes     □ No
                                                        LTG: Client will:
                                                                                                                                   LTG ?        □ Yes       □ No


                                                                                                                                         Progress to LTG?



                                                                                     2.                       2.

           R/T: (etiology / factor)
                                                        STG: Client will:                                                      Effectiveness of nursing interventions?




                                                                                     3.                       3.



           AEB: (s/sx; defining characteristics, lab,
                   diagnostic data)



                                                                                     4.                       4.

                                                                                                                                        Suggested revisions?
                               Part VI: Summary Statement

Once your process is complete, review each section in terms of specific Level Outcomes
including the RN’s role as a Provider of Care, Manager of Care, and Member of the Nursing
Profession. Write a short summary statement on how you have operationalized these concepts
meeting each of the three roles. Make them patient specific and focus on professionalism.
BIBLIOGRAPHY
PHYSICAL ASSESSMENT DATA                          Client Initials:            Date;
Time: BP     TPR         Finger stick              Height _________________   Weight _________________

Time: BP     TPR         Finger stick


REVIEW OF SYSTEMS (HIGHLIGHT CONCERNS R/T SYSTEMS ASSESSMENT)

NEUROLOGICAL
Oriented x 3
Behavior appropriate
PERLA
Active ROM x 4 Symmetrical strength
Speech clear and appropriate


CARDIOVASCULAR
HR regular
Extremities warm and pink
Capillary refill < 3.5 sec
Peripheral pulses present
IV access – Types

RESPIRATORY
Equal symmetrical chest expansion
Resp even and reg depth and rate
Clear breath sound all fields
Nailbeds, membranes pink

GASTROINTESTINAL
Abdomen soft flat non-tender
Active bowel sounds
Tolerated diet without nausea/vomiting
BM normal consistency & pattern for patient
Normal appetite, chewing
Swallows without difficulty
GENITOURINARY
Voids without pain, frequency or incontinence
Normal urine color odor

MUSCULOSKELETAL
Full ROM, Strength equal bilaterally
Steady gait and coordination
Devices / appliances
SKIN
Skin color / turgor normal
Skin warm dry intact
Mucous membranes moist
IV site condition, wounds, rashes, ulcers
PSYCHOSOCIAL
Reports stable living situations
Reports demonstrates stable support system
Mood and affect appropriate

PAIN
Location
Duration
Characteristic (Dull, sharp, stabbing, gnawing)
Scale - 0-10, Baker-Wong, Non communicative –
grimace, cries, guards
PHYSICAL ASSESSMENT DATA                          Client Initials:            Date;
Time: BP     TPR         Finger stick              Height _________________   Weight _________________

Time: BP     TPR         Finger stick

REVIEW OF SYSTEMS (HIGHLIGHT CONCERNS R/T SYSTEMS ASSESSMENT)

NEUROLOGICAL
Oriented x 3
Behavior appropriate
PERLA
Active ROM x 4 Symmetrical strength
Speech clear and appropriate


CARDIOVASCULAR
HR regular
Extremities warm and pink
Capillary refill < 3.5 sec
Peripheral pulses present
IV access – Types

RESPIRATORY
Equal symmetrical chest expansion
Resp even and reg depth and rate
Clear breath sound all fields
Nailbeds, membranes pink

GASTROINTESTINAL
Abdomen soft flat non-tender
Active bowel sounds
Tolerated diet without nausea/vomiting
BM normal consistency & pattern for patient
Normal appetite, chewing
Swallows without difficulty
GENITOURINARY
Voids without pain, frequency or incontinence
Normal urine color odor

MUSCULOSKELETAL
Full ROM, Strength equal bilaterally
Steady gait and coordination
Devices / appliances
SKIN
Skin color / turgor normal
Skin warm dry intact
Mucous membranes moist
IV site condition, wounds, rashes, ulcers
PSYCHOSOCIAL
Reports stable living situations
Reports demonstrates stable support system
Mood and affect appropriate

PAIN
Location
Duration
Characteristic (Dull, sharp, stabbing, gnawing)
Scale - 0-10, Baker-Wong, Non communicative –
grimace, cries, guards

								
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