MSU-NORTHERN LEVEL II NURSING CARE PLAN
Student Name: Patient’s Initials: Significant other: Doctor: Surgery Date: Allergies (in red) Date: Age/Sex: Room: Premorbid Living Arrangements:
Discharge Plans:
Chief complaint/reason for current hospital/ECF admission:
List all current diseases and medical diagnoses:
(On separate sheets of paper, prioritize and develop 3 of the Diseases with the following generic information for each one:) A. Pathophysiology B. Complications specific to the disease C. Medical Management D. Nursing Interventions specific to the disease – Standards of care
CHART REVIEW
DATE T P R BP Wgt Hgt: IDBW: PO IV Urine Drng BM’s Wgt trend: I & 0 trend: Diet: LAB Pt’s Norm 1 <>
TREATMENTS/PROCEDURES (nursing & medical):
MEDICATIONS
NAMES – TIMES DOSAGE – ROUTE CLASSIFICATION THERAPEUTIC ACTION/USE DOSING PARAMETERS SIDE EFFECTS CONTRAINDICATIONS
Sleep rest/Activity Sleep recently: Sleep hx: Feels rested upon arising? Repositions: Ambulation: Gait: Assist with ambulation: Visitors: Naps: Meds r/t sleep:
Pain/Comfort Pain Scale: Location: Character: Alleviating factors: Exacerbating factors: Grimace or guarding: Comfort in room: Repositioning: Pain with palpitation: Pain meds given: Result of meds: Safety Code status: Safe/Unsafe in room/halls: Risk for falls: Safety education: Able to be understood/understand: Reposition q 2h: Rails: Call light: Dizziness: Able to see, hear, smell: Asistive devices: Meds that make it more unsafe: Psychosocial/Cultural Resides: Works: Culture and needs: Hobbies: Concerns:
Hygiene/ADLs ADL needs: Toilieting: Feeding: Bathing: Oral care: Peri care: Dressing: Ambulation: Repostioning: AROM: PROM: Emotional/Spiritual Affect: Stress:
Spirituality: Depression tool score: Visitors: Alternative medicines: Social limits r/t disease process: Meds: Info: Sexuality/Family Male Female Position in family: Concerns: Appropriate apparrel
Meds r/t emotional needs: Patient Strengths:
Family Strengths:
Circulations/Cellular Nutrition Skin: Pulse: Heart Rhythm: Pulse deficit: Dorsalis pedis and post tibial pulses: Edema: Heart sounds: Capillary refill: Oral mucosa: Homan's sign: Jugular distention: Heart murmurs: Chest pains: Hx heart problems: Ted hose: SCDs: Lymph nodes: Meds: Food/GI Diet: Bowel sounds: Abdomen: Grimace and guarding: Nausea: Vomiting: Flatus: Self Feeding Ability: Breakfast: Lunch: Stools: Continent Incontent: Teeth: Throat: Swallow: Constipation: Meds: Growth and Development
Oxygenation/Respiration Resp rate: Quality: O2 source: O2 sats: Nasal flaring: Use of accessory muscles: Retraction: Bilateral chest expansion: Lung lobes: Cough: Color of skin and nails: Oral mucosa: Hx respiratory problems: Hx of smoking: Allergies: Distance can ambulate without getting SOB: Cyanosis: Clubbing: Med r/t oxygenation: Fluid/Elimination Intake: PO: IV fluid: IV meds: IV flush: Output: Continent urine: Incontinent urine: Foley catheter: Emesis: Drains:
Meds: Teaching/Learning/Discharge Assessment: Medications: Ambulation: Safety: Devices: Disease process: ADLS: Social Service Needs: Home Health referral:
Cognitive/Neurosensory Alertness: Responsive to verbal and tactile stimuli: Follows commands: Speech comprehensible: PERRLA: Eyes: Drainage: Glasses: Hearing problems: Numbness/tingling: Hand grips: Gait: Dizziness with rising or ambulation: Mental status assessment: Meds:
Integumentary/Muskuloskeletal Incisions: Jp: IV or PICC: Drainage: S/SX infection: Dressings: Drainage: Repositioning: Bony prominces: Tenting: Edema: Muscle strength: Gait: Muscle durability:: Skin: Grip strength: Braden scale assessment: Assistive devices: Bruising, breakdown, rashes, lesions: Skin treatments: Meds:
CLINICAL DECISION MAKING
PRIORITIZED NURSING Dx: PATIENTS OUTCOMES/GOALS NURSING INTERVENTIONS RATIONALE FOR INTERVENTIONS WITH SOURCES EVALUATIONS