Nursing care plan NURSING

					                             NURSING CARE PLAN SAMPLE DATABASE

Mr. Jose Rodriguez, an 84-   -year- -old client, was admitted to the hospital on 6/20/02 with shortness of
                                                                                -4
breath. This retired Hispanic grower, a widower, states that for the past 3- weeks he has had increasing
fatigue and shortness of breath. He visited his doctor two days ago, and his medication was increased. His
preferred foods are fresh fruits and vegetables, rice, red beans and tortillas. Mr. Rodriguez lives with one of
his daughters and her family since experiencing a myocardial infarction in 1988. He has six other children.
He is a Catholic and attends church regularly; however, since his declining health, he has been confined to
his home. He is visited at home weekly by his church pastor and/or representative. He speaks with pride
about his grocery store that he started for his family. He smoked two packs per day x 40 years and quit in
1990.
Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure (CHF) with acute
exacerbation. His medical history includes coronary artery disease x 10 years. He had a balloon
angioplasty in 2000 and an M.I. in 1988. He is hearing impaired and wears bilateral hearing aids. He wears
glasses and reads without difficulty. This is his third admission for CHF since his diagnosis five years ago.
Physician progress notes from 6/22/02 state: Condition improving; c/o decreasing SOB; chest x-           -ray
improving; serum K+ is 3.3, and weight decreased 8# in past two months.

Admitting history and          Moderate respiratory distress; crackles auscultated in left lung base
Physical exam                  Currently sleeping on 3 pillows at night to ease breathing.
 -20-
6- -02                         Nocturia X4 this past week.
                               Mild heart murmur; no JVD, peripheral pulses +2;
                                         -88-
                               VS: 98.6- -28, 176/94, Ht. 5’7”, Wt. 154#, Baseline BP 145/90
                               c/o increasing fatigue and severe shortness of breath (SOB)
                               O2 SAT level - 90% on room air. Denies chest pain.
                                              -
Medications ordered             -20-
                               6- -02       Digoxin 0.25 mg po QD
                                -20-
                               6- -02       Lasix 40 mg po bid
                                -20-
                               6- -02            -Bid 2.5 mg po qid
                                            Nitro-
                                -20-
                               6- -02       Metamucil 15 ml po q hs in glass of water/juice
                                -20-
                               6- -02       KCl 20 mEq po bid
Diagnostic tests results       6/22/02      Chest x-    -mild left ventricular hypertrophy; pulmonary
                                                    -ray-
                                            congestion resolving.
                               6/20/02      Serum electrolytes:
                                            Na+ 138 mEq/L
                                            K+ 3.3 mEq/L
                                            Ca+ 9.1 mg/dl
                                               -
                                            CL- 102 mEq/L
                               6/20/02      Serum albumin           2.8 g/dl
                               6/20/02      Serum digoxin level 2.6 ng/dl
                               6/20/02      Bun 30 mg/dl
                                            Cr 0.6 mg/dl
Other admitting orders         No added salt diet; I & O, daily wts, activity as tolerated
                               BRP with assist, VS Q 4 hours
                               O2 at 3L/min per nasal cannula
                               Heparin lock
Nursing Interview &            States “my old heart is just wearing out. I get this extra fluid every now
Observations                   and then. I come here to the hospital to get rid of it.” Seems well oriented
                               and is a fluent historian; accurately reported meds he had been on at home.
                               c/o constipation. Skin reddened over bony prominences. Currently
                               requires HOB elevated to ease breathing. Requires W/C for transport.
                               Needs ADL assist. Gait unsteady. Family at bedside.

                                                      -1-
                                                      - -                NSGCAREPLAN(Sample):1:1/06
                         SAMPLE NURSING CARE PLAN
RIVERSIDE COMMUNITY COLLEGE                     DATE
NURSING EDUCATION
STUDENT________________________________         SEMESTER
INSTRUCTOR____________________________          ROTATION

Client’s Initials   J.R.          Gender   M         Age     84           Code Status Full      Admission Date      -20-
                                                                                                                   6- -02
Presenting Signs/Symptoms (What brought the client to the hospital?)
                                       -4
         Increasing fatigue and SOB x 3- weeks

Admitting/Primary Diagnosis                                               Surgeries Related to this Admission
        Chronic CHF with acute exacerbation                                        None

Secondary Diagnoses (Diagnoses other than admitting diagnosis that impact this admission.)
        CAD (coronary artery disease). S/P MI (1988)

History of Present Illness (What led up to this hospitalization?)
                                               -4
         Client became more SOB and tired 3- weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented to
         E.R. with ↑ SOB and dyspnea.

Previous Surgical Procedure(s) / Date(s)
        Balloon Angioplasty (1 vessel) 2000

Health History (Include length of time client has had disease processes; significant family history; social issues.)
        CAD x 10 years. CHF x 5 years. MI 1988.

                                                                  -the-
Substance Use (Include use of tobacco, alcohol, street drugs, over- -counter drugs, length of use and time of last use.)
        2 PPD x 40 years. Quit 1990. Denies ETOH, drug use.

Allergies/Reactions        NKA
Religious Preference       Catholic                  Ethnicity Hispanic Marital Status W Occupation           Retired

Pathophysiology/Current Health Problems and Related Functional Changes: Define each primary and
secondary diagnosis and explain the disease process of each. Also include signs and symptoms, risk
factors, treatment options, possible complications, and functional changes that affect activities of daily
living (ADLs).                                       Source: Smeltzer and Bare, 2000
CHF: Congestive heart failure (CHF) often referred to as cardiac failure, is the inability of the heart to pump
sufficient blood to meet the needs of the tissues for oxygen and nutrients. As with coronary artery disease,
incidence increases with age. Common underlying conditions that lead to decreased myocardial
contractility include myocardial dysfunction (especially from coronary atherosclerosis), arterial
hypertension and valvular dysfunction (p. 622). Functional changes relate to inadequate tissue perfusion,
dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities, oliguria, sodium and fluid
retention. Increased pulmonary venous pressure leads to cough, SOB and pulmonary edema. Increased
systemic venous pressure may result in generalized edema and weight gain (p. 665).
CAD: The most common heart disease in the U.S. is atherosclerosis, which is an abnormal accumulation of
lipid, or fatty substances and fibrous tissue in the vessel wall. These substances create blockages or narrow
the vessel in a way that reduces blood flow to the myocardium (p. 594). Functional changes depend on the
degree of narrowing. Angina pectoris is recurrent chest pain that is brought on by physical exertion or
emotional stress and relieved by rest or medication (p. 595).



                                                              -2-
                                                              - -                 NSGCARE PLAN(Sample):2:1/06
Therapeutic/Multidisciplinary Treatment Plan: (Textbook)             Source   Smeltzer and Bare, 2000
        CHF: Medical: Reduce workload of heart; increase the force and efficiency of myocardial
        contraction and eliminate the excessive accumulation of body water by avoiding excess fluid intake;
        controlling the diet and monitoring diuretic and angiotensin-  -converting enzyme (ACE) inhibitor
        therapy (p. 665). Nursing: Administer medications and assess the medication effects. Assess
        patient’s: intake and output; weight; lung sounds; vital signs; skin turgor and mucous membranes.
        Assess patient for JVD, edema and signs/symptoms of fluid overload (p. 668). Nurses perform
        counseling and education concerning regular exercise, sodium restriction, and avoidance of
        excessive fluid intake, alcohol and smoking (p. 668). Pharmacist: Review of medications used for
        treatment of CHF including ACE inhibitors, diuretic therapy, digitalis. Monitoring blood levels such
        as digoxin (in collaboration with MD and nursing) (p. 666). Registered dietitian: Nutrition
        assessment and counseling regarding sodium restriction, avoidance of excessive fluid intake and
        alcohol (p. 668). Respiratory therapist: Administer oxygen therapy based on the degree of
        pulmonary congestion and resulting hypoxia. Some patients may need supplemental oxygen therapy
        during activity. Others may require hospitalization and endotracheal intubation (p. 666).
        CAD: Prevention of CAD by controlling these risk factors is important: high cholesterol, cigarette
        smoking, hypertension and diabetes mellitus (p. 595). If CAD is associated with angina, medical
        management with drugs and control of risk factors is implemented to decrease the oxygen demands
        of the myocardium and to increase the oxygen supply (p. 598). Revascularization procedures include
        coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty
        (PTCA, also known as balloon angioplasty) (p. 598). Medications include: Ntg, Beta blockers,
                                                                          -599).
        calcium channel blockers, antiplatelet and anticoagulants (pp. 598-



                           Prescribed Treatments (as per physician’s orders)
Oxygen:          3 LPM via N/C
Respiratory Treatment:       N/A
IV Infusion:        Heparin lock
Diet:       NAS
Feeding:         Requires assistance
Bowel/Bladder:         BRP with assistance
Hygiene:         Assist
Activity:        As tolerated with assist
Other:           I & O; daily wts.
                 Requires W/C for transport
                 Elevate HOB




                                                      -3-
                                                      - -              NSGCAREPLAN(Sample):3:1/06
  -
T - herapeutic effect
A - ction
  -                                                             PRESCRIBED MEDICATIONS
  -
C - ontraindications
  -
T - oxic effects/Side effects                                                                                   Allergies    NKA
  -
I - nterventions                                                                                                    -
                                                                                                                MSI - minimum safe infusion
  -
S - afe dose                                     Source     Mosby’s Nursing Drug Reference 2002                       -
                                                                                                                MSD - minimum safe dilution


Drug Classification/     Time    Therapeutic       Action (A)     Contraindications        Toxic Effects (T)       Interventions (I)    Ordered       Safe Dose (S)
Medication               Med     Effect (T)                       (C)                      & Side Effects                               Date          include
Generic/Brand            Due                                                               (include common/                                    Stop   MSI/MSD
dose/route/interval                                                                            -threatening)
                                                                                           life-                                               Date   (IV Meds)*

Digoxin 0.25             0900 Increase cardiac     Inhibits       Hypersensitive to        Headache,               Apical pulse 1       6- -02
                                                                                                                                         -20-         Maintenance
P.O. q day               (Hold output              sodium-  -     digitalis; V. fib; V.    dysrhythmias,           minute. Hold P                          -0.5 mg/day
                                                                                                                                                      0.063-
(Lanoxin)                Dig                       potassium      tach; carotid sinus      hypotension, AV         < 60. Assess                       Dose safe.
Cardiac glycoside        level                     ATPase.        syndrome; 2nd or 3rd     block, blurred          lytes, BUN/Cr,
                         2.6)                      Results in     degree heart block.      vision,                 ALT, AST, H&H.
                                                   increased                               yellow- -green halos,   I & O, daily wts,      -20-
                                                                                                                                         7- -02
                                                   cardiac                                 N/V                     √ dig level.
                                                   output.
Lasix 40 mgs.            0900 Decrease edema       Inhibits       Hypersensitive to        Circulatory             Assess client for    6- -02
                                                                                                                                         -20-            -80
                                                                                                                                                      20- mg/day in
P. O. BID                1700 and blood            reabsorption   sulfonamides, anuria,    collapse, loss of       s/s dehydration.                   a.m. May give
(furosemide)                  pressure             of Na+ and     hypovolemia, infants,    hearing,                adm in a.m. K+                     another dose in 6
Loop diuretic                                      CL-- at        lactation, electrolyte   hypokalemia,            replacement if                     hours up to 600
                                                   proximal,      depletion.               hypochloremic           < 3.0. adm. with                   mg/day.
                                                   distal                                  alkalosis, ↓ mg++,      food if nauseated.     -20-
                                                                                                                                         7- -02       Dose safe.
                                                   tubules and                             hyperuricemia,
                                                   loop of                                 hypocalcemia,
                                                   Henle.                                  hyponatremia,
                                                                                           hyperglycemia,
                                                                                           nausea, polyuria,
                                                                                           renal failure,
                                                                                           thrombocytopenia,
                                                                                           agranulocytosis,
                                                                                           leukopenia,
                                                                                           neutropenia,
                                                                                           anemia, rash
                                                                                           pruritis,
                                                                                           Stevens-  -Johnson
                                                                                           syndrome.
                                                                               -4-
                                                                               - -                                                                -5:1/06
                                                                                                                             NSGCAREPLAN(Sample):4-
   Drug Classification/    Time    Therapeutic         Action (A)     Contraindications        Toxic Effects (T)     Interventions (I)    Ordered       Safe Dose (S)
   Medication              Med     Effect (T)                         (C)                      & Side Effects                             Date          include
   Generic/Brand           Due                                                                 (include common/                                  Stop   MSI/MSD
   dose/route/interval                                                                             -threatening)
                                                                                               life-                                             Date   (IV Meds)*
   Nitro--Bid 2.5 mgs.     0900 Prevent chest          Dilates        Hypersensitive to        Postural              Assess BP, pulse,    6- -02
                                                                                                                                           -20-         Sustained release
   P.O. QID                1300 pain; increase         coronary       nitrates; severe         hypotension,          pain. May                          capsule 2.5 mg
   (Nitroglycerin)         1700 cardiac output         arteries;      anemia; increased        collapse, HA,         develop tolerance.                 (lowest dose)
   Vasodilator (Nitrate)   2100                        decreases      intracranial pressure;   flushing, dizziness   Adm. with 8 oz.                       -12
                                                                                                                                                        q6- hrs. on
                                                       preload and    cerebral hemorrhage                            H20 on empty                       empty stomach.
                                                       afterload                                                     stomach, 1 hr.         -20-
                                                                                                                                           7- -02       Safe Dose.
                                                                                                                     before or 2 hrs.
                                                                                                                     after
** Metamucil               2100 Prevent                Bulk--         Hypersensitivity,       N/V, anorexia,         Assess then adm.     6- -02
                                                                                                                                           -20-         1- teaspoons in
                                                                                                                                                          -2
   15 ml P. O. qHs         (Hold, constipation         forming        intestinal obstruction, diarrhea, cramps       alone for better                   8 oz. H2O BID or
   (Psyllium)              √                           laxative       abd. pain, N/V,                                absorption. Give                   TID. Ordered dose
   Bulk--forming           PDR)                                       impaction                                      with 8 ozs of H20                  outside safe.**
   laxative                                                                                                          followed by 8 oz.
                                                                                                                     fluid                  -20-
                                                                                                                                           7- -02

   KCl 20 mEq              0900 Replace                Needed for     Severe renal disease,    Cardiac depression,   Assess EKG, K+        -20-
                                                                                                                                          6- -02        40--100 mEq/day in
   P. O. BID               1700 potassium              transmission   hemolytic disease,       dysrhythmias,         level, I & O,                      divided doses.
   Potassium                                           of nerve       Addison’s,               arrest, peak T        ↓ u. o., heart.
   supplement                                          impulses       hyperkalemia, acute      waves, low R &        Adm. with or
                                                       and cardiac    dehydration,             RST, prolonged PR     after meal. Do
                                                       contraction    extensive tissue         interval, wide QRS    not give IM or SQ      -20-
                                                                                                                                           7- -02
                                                                      breakdown                                      powder, dissolve
                                                                                                                     in 8 oz. cold
                                                                                                                     water/juice
  *All meds being titrated (i.e. heparin) state appropriate lab results related to medication administration.




                                                                                    -5-
                                                                                    - -                                                             -5:1/06
                                                                                                                               NSGCAREPLAN(Sample):4-
    ADMISSION DATE 6/20/02 ADULT LABORATORY/ DIAGNOSTIC TOOL SOURCE: Nurse’s Manual of Lab Tests (Watson & Jaffe)
    Test        Range             Adm.   Date/    Date/   Identify ↑ ↓ WNL Significance/ Trends
                                  Result Result   Result
C   WBC         5,000-10,000/
B               mm3
C   RBCs        4.2-6.1
                 x 106/µg
    Hgb         11.5-17.5
                g/dl
    Hct         40-52%

    MCV                90-95
                       mm3
    MCH                27-31 µg

    MCHC               32-36 g/dl

    RDW                11%-14.5%

    Retic.             0.5%-3.1%

    Platelet           150,000-
                       400,000 mm3
W   Neutrophils        55-70%
B
C   Lymphocytes        20-40%

D   Monocytes          2-8%
i
f
    Eosinophils        1-4%
f

    Basophils          0.5-1.0%

    Sodium             135-145 mEq/L       138                             WNL – most abundant cation in ECF. Normal fluid
L                                                                          status. (p. 275)
y
    Chloride           98-106              102                             WNL – most abundant anion in ECF. Normal fluid
t
e                       mEq/L                                              status. (p. 278)
s   Potassium          3.5-5.0             3.3                             ↓ Hypokalemia secondary to Lasix (diuretic therapy).
                       mEq/L                                               (p. 276)
    CO2                24-30
                       mEq/L
    Magnesium          1.3-2.1
                       mEq/L
    Calcium            9.0-10.5            9.1                             WNL – Reflects overall calcium metabolism and
                       mg/dl                                               indicates normal regulation of calcium.
C
    INR                See lab result
o
a
g   PT                 11-12.5
                       seconds
    PTT                60-70 seconds
    On anticoag. →     1.5-2.5 x control
R   BUN                10-20 mg/dl         30                              ↑ Evaluates kidney function. Reduced renal blood
e                                                                          flow, no renal damage. Possible protein catabolism.
n   Creatinine         0.5-1.2 mg/dl       0.6                             WNL – evaluates kidney function. No renal damage.
a                                                                          (p. 162)
l
             Note: Normal value range will vary depending on laboratory used.
                                                             -6-                   NSGCAREPLAN(Sample):6-7:1/06
     Test              Range             Adm.      Date/    Date/    Identify ↑ ↓ WNL Significance/ Trends
                                         Result    Result   Result
     Glucose           70-110 mg/dl
B
l    Hgb A1c           4.4-6.4%
o
o    AST               0-35 U/L
d

C    ALT               4-36 IU/L
h
e    Acid              0.13-0.63 U/L
m.   Phosphatase

     Ammonia           80-110 µg/dl

     LDH               100-190 U/L

     Amylase           30-220 U/L

     Lipase            0-160 U/L

     Phosphorus        3-4.5 mg/dl

     Alk. Phos.        30-120 U/L

     Total Bilirubin   .3-1.0 mg/dl

     Cholesterol       <200 mg/dl

     Uric acid         2.7-8.5 mg/dl

     Total protein     6.4-8.3 g/dl

     Albumin           3.5-5.0 g/dl      2.8                         ↓ Evaluates protein deficiency, hemodilution,
                                                                     ↓ protein in diet, malnutrition (p. 157)
     Globulin          2.3-3.4 g/dl

     Digoxin level     0.8- 2.0 ng/ml    2.6                         ↑ Possible early digoxin toxicity. (p. 992)

     Theophylline      10-20 µg/ml
     level

     Dilantin level    10-20 µg/ml



     Urinalysis                         Diagnostic Tests             ABGS
     Date/Result                      Date/Results                   Date/Results            Date/Results
     Color                            X-rays CXR 6-22 mild           pH                      pH
     Appearance                                Left Ventricular      pCO2                    pCO2
     Spec. gravity                             Hypertrophy           pO2                     PO2
     Protein                          Nuclear scans      Pulmonary   B.E                     B.E.
     Glucose                                             Congestion  O2 sat                  O2 sat
     Ketones                          CT/MRI             Resolving   Comments ___________________________
     Bacteria_________________________                                       _____________________________
     Blood________________________ Other                                     _____________________________
     Other_________________________________________________________________________________________
                 Note: Normal value range will vary depending on laboratory used.
                                                           -7-                 NSGCAREPLAN(Sample):6-7:1/06
ADMISSION DATE _________      LABORATORY/ DIAGNOSTIC TOOL         SOURCE:______________________
Test        Range          Adm.     Date/    Date/   Identify ↑ ↓ WNL Significance/ Trends
                           Result   Result   Result




                                             -8-           NSGCAREPLAN(Sample):8-9:1/06
ADMISSION DATE _________      LABORATORY/ DIAGNOSTIC TOOL          SOURCE:______________________
Test        Range          Adm.     Date/    Date/   Identify ↑ ↓ WNL Significance/ Trends
                           Result   Result   Result




                                             -9-           NSGCAREPLAN(Sample):8-9:1/06
                                           CONCEPT MAP

Developmental Stage           Very Old Age                   -
                                                       Psycho- Social Crisis   Immortality vs. Extinction


      -Illness Continuum: Maximum Health
Health-                                                Health     Illness      Death
                                                                       →
Oxygen Needs/Circulation             Elimination                                    Nutrition/Hydration
Admitted 6/20/02 SOB                 Nocturia x 4 past week                        Prefers fruits/vegs, rice,
Increasing fatigue SOB x             I&O                                             red beans, tortillas
   3- 4 weeks
    -                                c/o Constipation                              K+ 3.3. KCL
O2 3 LPM n/c                         Metamucil                                     Wt. ↓ 8 pounds
MI 1988
                              Medical Diagnoses:                                   Na+ 138
Smoked 2 PPD x 40 yrs.                                                             K+ 3.3
Quit 1990                      1.    Chronic CHF with acute                        Ca+ 9.1
CHF with acute exacerba-             exacerbation.                                 Cl- 102
tion                                                                               Albumin 2.8 ↓
CAD x 10 yrs.                  2.    CAD                                           NAS diet
Balloon angioplasty 2000                                                           Daily Wts
Mod. resp. distress                                                                H.L.
Crackles L lung base           Problem List/Nursing Diagnosis
Elevate HOB                    Prioritize according to Maslow’s Hierarchy
Sleeps 3 pillows               1.    Impaired gas exchange.
Mild heart murmur
BP 176/94 VS Q 4 hrs.          2.    Decreased cardiac output.
O2 sat 90%                                                                          Safety/Skin/Wounds/
            -
6/22 CXR - mild L              3.    Nutrition, imbalanced,                         Drains/Infections/
   ventricular hypertrophy;          less than body requirements.                   Sensory
pulm congesting resolving
Dig level ↑ 2.6                4.    Perceived constipation.                       Hearing impaired
Digoxin
                                                                                   Bilat H.A.s.
Lasix; Nitro- -Bid
                               5.    Impaired physical mobility.                   Glasses
                                                                                   Reads with no diff.
Neurological/Neurovascular           Anxiety                                       Skin reddened over
Oriented x 4                         Concerns/Fear                                   bony prominences
Alert                                Knowledge Needs                               Gait unsteady
Fluent historian
                                                       -
                                     Confined to home 3- 4 weeks
                                     Third admission CHF


Love/Belonging/Culture               Rest/Activity                                  Comfort/Sexuality
Coping/Body Image

Retired Hispanic grower              Activity as tolerated                          Denies chest pain
Widower                              BRP with assistance                            Widower
Lives with daughter                  W/C for transport
Six children                         Assist ADL
Catholic, attends church regularly
Family at bedside



                                                   -
                                               - 10-               NSGCAREPLAN(Sample):10:1/06
   NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK
Oxygen Needs/Circulation                         Tissue Perfusion, Ineffective                       Community Coping, Readiness for Enhanced
Breathing                                        Urinary Elimination, Impaired                       Delayed Development, Risk for
Airway Clearance, Ineffective                    Urinary Elimination, Readiness for Enhanced         Family Coping: Compromised, Ineffective
Aspiration, Risk for                             Urinary Retention                                   Family Coping: Disabled
Breathing Pattern, Ineffective                                                                       Family Coping: Readiness for Enhanced
Gas Exchange, Impaired                           Rest/Activity                                       Family Processes, Dysfunctional:
Infection, Risk for                              Activity Intolerance                                    Alcoholism
Sudden Infant Death Syndrome, Risk for           Activity Intolerance, Risk for                      Family Processes, Interrupted
Suffocation, Risk for                            Disuse Syndrome, Risk for                           Family Processes, Readiness for Enhanced
Ventilation, Impaired, Spontaneous               Diversional Activity Deficient                      Growth and Development, Delayed
Ventilatory Weaning                              Fatigue                                             Loneliness, Risk for
    Response, Dysfunctional                      Mobility, Impaired Bed                              Parental Role Conflict
Circulation                                      Mobility, Impaired Physical                         Parent/Infant/Child Attachment,
Cardiac Output, Decreased                        Mobility, Impaired Wheelchair                           Impaired, Risk for
Fluid Balance, Readiness for Enhanced            Perioperative Positioning Injury, Risk for          Parenting, Impaired
Fluid Volume Deficit                             Sedentary Lifestyle                                 Parenting, Impaired, Risk for
Fluid Volume Excess                              Sleep Deprivation                                   Parenting, Readiness for Enhanced
Fluid Volume, Risk for Deficit                   Sleep Pattern, Disturbed                            Role Performance, Ineffective
Fluid Volume, Risk for Imbalanced                Sleep, Readiness for Enhanced                       Social Interaction, Impaired
Tissue Perfusion, Ineffective                    Transfer Ability, Impaired                          Social Isolation
(specify: renal, cerebral,                       Walking, Impaired                                   Violence, Risk for
cardiopulmonary, gastrointestinal, peripheral)   Comfort/Sexuality                                   Anxiety Concerns/Fear/Knowledge Needs
Neurological/Neurovascular                       Comfort                                             Self-Esteem
Neurological                                     Pain, Acute                                         Adjustment, Impaired
Confusion, Acute                                 Pain, Chronic                                       Anxiety
Confusion, Chronic                               Sexuality                                           Body Image Disturbed
Environmental Interpretation Syndrome,           Sexuality Pattern, Ineffective                      Coping, Defensive
    Impaired                                     Sexual Dysfunction                                  Coping, Ineffective
Infant Behavior, Disorganized                    Safety/Skins/Wounds/Infections/Sensory              Coping, Readiness for Enhanced
Infant Behavior, Readiness for                   Temperature                                         Death Anxiety
    Enhanced Organized                           Hyperthermia                                        Decisional Conflict (Specify)
Infant Behavior, Risk for Disorganized           Hypothermia                                         Denial, Ineffective
Intracranial, Decreased Adaptive                 Temperature, Risk for Imbalanced Body               Fear
    Capacity                                     Thermoregulation, Ineffective                       Grieving, Anticipatory
Memory, Impaired                                 Skin                                                Grieving, Dysfunctional
Thought Processes, Disturbed                     Infection, Risk for                                 Grieving, Dysfunctional, Risk for
Neurovascular                                    Injury, Risk for                                    Hopelessness
Dysreflexia, Autonomic                           Latex Allergy Response                              Personal Identity, Disturbed
Dysreflexia, Risk for Autonomic                  Latex Allergy Response, Risk for                    Post-Trauma Syndrome
Peripheral Neurovascular Dysfunction,            Protection, Ineffective                             Post-Trauma Syndrome, Risk for
    Risk for                                     Skin Integrity, Impaired                            Powerlessness
Nutrition/Hydration                              Skin Integrity, Impaired, Risk for                  Powerlessness, Risk for
Breastfeeding, Effective                         Tissue Integrity, Impaired                          Rape-Trauma Syndrome
Breastfeeding, Ineffective                       Physical                                            Rape-Trauma Syndrome, Compound Reaction
Breastfeeding, Interrupted                       Falls, Risk for                                     Rape-Trauma Syndrome, Silent Reaction
Dentition, Impaired                              Growth, Risk for Disproportional                    Religiosity, Impaired
Failure to Thrive, Adult                         Mobility, Impaired Physical                         Religiosity, Readiness for Enhanced
Fluid Volume, Deficit                            Perioperative Positioning Injury, Risk for          Religiosity, Risk for Impaired
Fluid Volume, Deficit, Risk for                  Trauma, Risk for                                    Relocation Stress Syndrome
Infant Feeding Pattern, Ineffective              Self-Care Deficit, Bathing/Hygiene                  Relocation Stress Syndrome, Risk for
Nausea                                           Self-Care Deficit, Dressing/Grooming                Self-Esteem, Chronic Low
Nutrition: Imbalanced, Risk for                  Self-Care Deficit, Toileting                        Self-Esteem, Situational Low
    More Than Body Requirements                  Surgical Recovery, Delayed                          Self-Esteem, Situational Low, Risk for
Nutrition: Imbalanced, Less                      Wandering                                           Self-Mutilation
    Than Body Requirements                       Perception                                          Self-Mutilation, Risk for
Nutrition: Imbalanced, More                      Energy Field, Disturbed                             Sorrow, Chronic
    Than Body Requirements                       Environmental Interpretation Syndrome, Impaired     Spiritual Distress
Nutrition: Readiness for Enhanced                Infant Behavior, Disorganized                       Spiritual Distress, Risk for
Oral Mucous Membranes, Impaired                  Infant Behavior, Disorganized, Risk for             Spiritual Well-Being, Readiness for Enhanced
Self-Care Deficit, Feeding                       Infant Behavior, Readiness for                      Self-Actualization
Swallowing, Impaired                                 Enhanced Organized                              Health Maintenance, Ineffective
Elimination                                      Poisoning, Risk for                                 Health Seeking Behaviors (Specify)
Bowel                                            Self-Mutilation                                     Home Maintenance, Impaired
Constipation                                     Self-Mutilation, Risk for                           Knowledge, Deficient (Specify)
Constipation, Perceived                          Sensory/Perception, Disturbed (specify):            Knowledge, Readiness for Enhanced (Specify)
Constipation, Risk for                               Visual, Kinesthetic, Auditory,                  Noncompliance
Diarrhea                                             Gustatory, Tactile, Olfactory                   Therapeutic Regimen: Community, Ineffective
Incontinence, Bowel                              Suicide, Risk for                                       Management of
Nausea                                           Unilateral Neglect                                  Therapeutic Regimen: Families, Ineffective
Urinary                                          Violence, Risk for Other-Directed                       Management of
Fluid Volume, Risk for Imbalanced                Violence, Risk for Self-Directed                    Therapeutic Regimen: Management, Effective
Infection, Risk for                              Love/Belonging/Culture/Coping/Body Image            Therapeutic Regimen: Management, Ineffective
Incontinence, Functional                         Adjustment, Impaired                                Therapeutic Regimen: Management,
Incontinence, Reflex                             Caregiver Role Strain                                   Readiness for Enhanced
Incontinence, Risk for Urge                      Caregiver Role Strain, Risk for
Incontinence, Stress                             Communication, Impaired Verbal
Incontinence, Total                              Communication, Readiness for Enhanced
Incontinence, Urge                               Community Coping, Ineffective


                                                                -11-                               NSGCAREPLAN(Sample):11:1/06
Section 1: Physical Assessment                                                 *Include all dates/times of care provided.
 GENERAL APPEARANCE                        DATE/TIME INITIAL ASSESSMENT                 Date/Time*              Related Nursing Diagnoses
 Admitted in moderate                       - -
                                           6- 23- 02                  0800              Explanation of          (Circle appropriate
 repiratory distress                       Condition has stabilized since initial       Abnormal                diagnoses)
 Allergies: NKA                            assessment in E.R.                           Assessment Factors
                            -developed, Well-
Thin, Obese, Emaciated, Well-               -nourished, No Acute Distress (NAD)                                Latex Allergy Response
Height 5’7”      Weight 154 lbs.      BMI     24                                                               Latex Allergy Respoonse,
Admitting Vital Signs             -
                         98.6 - 88- 28 176/94                                                                     Risk for
I. PHYSIOLOGIC ASSESSMENT
    A. OXYGENATION
           1.   BREATHING                                                              Moderate resp.p                y           ,
                                                                                                               Airway Clearance, Ineffective
                                                                                       distress, uses 3
                                                                                       di                      Aspiration, Risk for
Respiratory Rate          28          Rhythm: -Regular      =Irregular                 pillows at night, c/o   Breathing Pattern, Ineffective
                                      Depth: -Deep          =Shallow                   ↑ fatigue & SOB,        Gas Exchange, Impaired
        -No distress                  -Dyspneic             -Apneic ___ sec.           crackles L base         Infection, Risk for
        =Labored                      -Accessory muscle use -Tachypneic                                        Suffocation, Risk for
      R   L                       L     R           BREATH SOUNDS                                              Ventilation, Impaired,
                                   Cl   Cl          Cl - Clear                                                    Spontaneous
      Cl        Cl                                  Cr - Crackles                                              Ventilatory Weaning
                                                    Wh - Wheezing                                                 Response, Dysfunctional
      Cl                          Cr Cl
                     Cl                             D - Decreased
                                                    A - Absent
     Anterior                    Posterior
Oxygen Therapy:
-RA =FiO2 3 L / or %                 =NC -Mask -Trach -Other
O2 Saturation: -N/A =q 8 hr              -Continuous pulse oximeter
Pulse Oximetry Readings (Identify on R.A. or O2): 90RA ; ______; ______
Chest Config:         =Symmetrical -Asymmetrical -Flail
Cough:      -No cough -Weak -Strong -Frequent =Infrequent
            =Nonproductive -Productive Description:
Color _______ Odor ________ Viscosity ________ -Incentive Spirometer
Shape of Chest: AP diameter 1:2, barrel, pectus excavatum,
(circle)        pectus carinatum, kyphotic
Drainage: Chest Tube/Pleuravac: -R                   -L -Water seal only
Suction ____ cm of water =N/A
Medications R/T Breathing: -Yes               =No Type
           2.   CIRCULATION                                                            Weak radial &                         p ,
                                                                                                               Cardiac Output, Decreased
Heart Rate    88    Rhythm Regular                                                     dorsalis pedal
                                                                                       d      li   d l         Fluid Balance, Readiness for
Heart Sounds: Describe    S1, S2, Mild heart murmur                                    pulses bilat. cap          Enhanced
Neck Veins (45o angle):       =Flat -Distended                                         refill prolonged.       Fluid Volume Deficit
BP:     176/94          R           L             Apical Pulse: 88                     Bilat ankle edema -     Fluid Volume Deficit, Risk for
                                                                                       pitting 2+ BP           Fluid Volume Excess
   Arterial       C        B    R     F     PT       DP     D - Doppler                176/94                  Fluid Volume, Risk for
   Pulses                                                   A - Absent                 Baseline 145/90            Imbalanced
                                                            1+ - Barely Palpable                               Tissue Perfusion, Ineffective
   Right/                                                   2+ - Weak
   Left         3+ 3+ 3+ 3+    2+ 2+ 3+ 3+ 3+ 3+ 2+ 2+                                                            (specify: renal, cerebral,
                                                            3+ - Normal
                                                                                                                  cardiopulmonary,
                                                            4+ - Full Bounding
                                                                                                                  gastrointestinal, peripheral)
Capillary Refill: -Brisk <3 sec.                 =Prolonged >3 sec. _________ sec.
Nail bed Color: =Pink                            -Pale    -Cyanotic
Chest Pain: =No            -Yes           Describe
Edema:  Location    Bilat. Ankle
-None -Generalized -Non- pitting =Pitting 1 + 2 + 3 + 4 + (circle)
                        -
-Other
Pacemaker: =N/A -Permanent                       Type
           -External Rate_____
           Location:

                                                                            -
                                                                        - 12-                   NSGCAREPLAN(Sample):12:1/06
        2.   CIRCULATION (Continued)                                       Date/Time          Related Nursing Diagnoses
                                                                           Explanation of     (Circle appropriate
                                                                           Abnormal           diagnoses)
                                                                           Assessment Factors
Homan’s sign: Left: -pos. =neg.          Right: -pos. =neg.
Calf redness/tenderness: Left: -yes =no Right: -yes =no
    Anti- embolism stockings: =N/A -Remove/Replaced q shift
         -
    Sequential compression device: =N/A -Remove/Replaced q shift
    -Other
IV’s / INVASIVE LINE MONITORING
Type/Port     Solution      Rate       Dosage     Location          Site
ID**                                                                Code
 Heparin Lock                                     R wrist              C

                                                                           Digoxin .25 qd
                                                                           Nitro-    2.5
                                                                           Nit - Bid 2 5
*SITE CODE:       **ID
                                                                           Lasix 40 BID
    C - Clear     INFUSION           c       -     controller
                                                                           KCl 20 mEq BID
    S - Swelling DEVICE:             p       -     pump
    R - Redness                      pca+    -     PCA
                                                                           Digoxin level 2.6 -
    I - Inflamed                     g       -     gravity
                                                                           hold digoxin and
    DI - Dsg Dry & Intact
                                                                           notify M.D.
Medications R/T Circulation: =Yes    -No Type       See above
        3.   NEUROLOGICAL                                                                                   ,
                                                                                                 Confusion, Acute
                                                                                                 Confusion, Ch i
                                                                                                 C f i        Chronic
Level Of Consciousness:                                                                          Environmental Interpretation
=Awake =Alert =Oriented x 4 (time, place, person, event)                                            Syndrome, Impaired
-Restless -Drowsy -Sedated    -Confused                                                          Infant Behavior, Disorganized
Glasgow Coma Scale: (Circle number that applies.)                                                Infant Behavior, Readiness for
a) Best eye opening: 4 Spontaneously 3 To Speech 2 To Pain 1 None                                   Enhanced Organized
                                                                                                 Infant Behavior, Risk for
b) Best verbal response:     5 Oriented   4 Confused                                                Disorganized
       3 Inappropriate words 2 Incomprehensible sounds 1 None                                    Intracranial, Decreased Adaptive
                                                                                                    Capacity
c)   Best motor response:      6 Obeys commands 5 Localizes to pain                              Memory, Impaired
                               4 Withdraws 3 Flexion (decorticate)                               Thought Processes, Disturbed
                               2 Extension (decerebrate) 1 None
Total Glasgow Coma Scale 15 / 15 (Add a, b, c above)
=PERRL           -Pinpoint        -Fixed
-Dilated, but reactive to light -Dilated, nonreactive
Unequal:    -R>L        -L>R -Dolls eyes             -Other
Brain Stem Signs:
   -
(+/- ) X N/A ____ cough ____ gag ____ corneal ____ Babinski
Sensation:     Location   all extremities
=Intact      -Numbness -Absent     -Tingling
Communication: =Verbal -Writes notes -Mouths words
               -Nods head appropriately to yes/no questions
Medications R/T Neurological Condition: -Yes     -No Type
        4.   NEUROVASCULAR                                                                         y        ,
                                                                                                 Dysreflexia, Autonomic
                                                                                                 Dysreflexia, Ri k f
                                                                                                 D     fl i Risk for
Extremities Examined:                           CSM q ___ hr                                        Autonomic
Traction/Cast: =N/A Type                                                                         Peripheral Neurovascular
Color:       -Pink -Reddened -Blue -Blanched                                                        Dysfunction, Risk for
Temperature: -Cool -Warm -Hot
Movement: -Active -Passive         -Limited
Sensation: -Numbness           -Tingling  -Pain
Restraints: =N/A       Type                       CSM q ___ hr
-Restraint Protocol Instituted -Remove/Replaced q shift



                                                                -
                                                            - 13-                   NSGCAREPLAN(Sample):13:1/06
B. NUTRITION                                                                  Date/Time            Related Nursing Diagnoses
                                                                              Explanation of       (Circle appropriate
                                                                              Abnormal             diagnoses)
                                                                              Assessment Factors
Abdomen: =Soft -Firm -Hard -Tender -Distended _____cm.                        Serum albumin        Breastfeeding, Effective
                                                                              ↓ 2.8
                                                                                 28                Breastfeeding,
                                                                                                   Breastfeeding Ineffective
Bowel Sounds: =Active -Hyper -Hypo -Absent                                                         Breastfeeding, Interrupted
Flatus: =Yes -No                                                              Wt loss 8 lbs. in    Dentition, Impaired
                                                                              2 months             Failure to Thrive, Adult
Diet:   Type NAS     -NPO      -TPN -Tube feeding                             Lack of appetitie    Fluid Volume, Deficit
Meal: =Breakfast -Lunch -Dinner % taken      90%___                           and nausea           Fluid Volume, Deficit, Risk for
                                                                                                   Infant Feeding Pattern,
Type gastric tube                =N/A       -Placement Verified               Retired grocer,          Ineffective
Purpose: -Feeding -Decompression -Other                                       Hispanic, lives with Nausea
Formula: Type              Rate       cc’s q ___ hrs =N/A                     daughter             Nutrition: Imbalanced, Risk for
                                                                              Prefers fruit/veg,      More Than Body
Suction: =N/A -Intermittent -Low continuous                                                           Requirements
Drainage: Describe                                                            rice, red beans,     Nutrition: Imbalanced, Less
                                                                              tortillas               Than Body Requirements
Mucous Membranes: =Moist -Dry -Cracked -Sores -Patches                        Consider dietary     Nutrition: Imbalanced, More
=Pink -Dusky - Other                                                          consult                 Than Body Requirements
                                                                                                   Nutrition: Readiness for
Dentures: -Full -Upper -Lower =N/A                                                                      Enhanced
                                                                                                                  Membranes
                                                                                                     Oral Mucous Membranes,
Diet toleration: =Anorexia =Nausea -Vomiting                                                            Impaired
=Weight Loss: Amount         8 lbs.     Time Period 2 mos.          -N/A                                 -
                                                                                                     Self- Care Deficit, Feeding
24o Intake 1500 24o Output 1800 on 6/25 Balance: -Positive =Negative/300 cc                          Swallowing, Impaired
Blood Glucose Monitoring q ___ hrs Time/Result _____________ =N/A
=Self- feed -Assist- feed -Swallowing precautions
       -              -
Medications R/T Nutrition: -Yes -No Type
C. ELIMINATION                                                                                       Constipation
                                                                                                     Constipation,
                                                                                                     Constipation Perceived
      1. BOWEL                                                                                             p      ,
                                                                                                     Constipation, Risk for
                                                                                                     Diarrhea
                                                                                                     Di h
Stool: =Formed -Loose -Impacted Last BM                       -
                                                            6- 22                                    Incontinence, Bowel
         Color:         Brown                    -Regular -Irregular                                 Nausea
Outlet: =Rectum -Colostomy -Ileostomy -Rectal Tube -Fistula
Output: Tube Drainage ______ cc’s Describe:
Stoma:        =N/A -Pink -Edema -Dusky
Surrounding Skin: -D/I       -Excoriated -Other
Toileting: =Self -Assist          History Laxative Use: -No   =Yes
Medications R/T Bowel: =Yes -No Type                Metamucil
      2. URINARY                                                              Nocturia x 4 p
                                                                                           past      Fluid Volume, Risk for
                                                                              weekk                     Imbalanced
GU Drainage: =Voiding -Straight Catheter q ___ hrs                                                   Infection, Risk for
                  -Indwelling Foley -3- way cath (irrigation)
                                          -                                   BUN 30 mg/dl           Incontinence, Functional
                                                                              Cr 0.6 mg/dl           Incontinence, Reflex
                  -External cath -Other                                                              Incontinence, Risk for Urge
                                                                              Daily wts.
Other:       -Bladder Training -Catheter Care -Hourly Urine Output                                   Incontinence, Stress
Bladder Irrigation:    -Continuous -Manual Solution:                                                 Incontinence, Total
                                                                                                     Incontinence,
                                                                                                     Incontinence Urge
Urine: =Clear -Cloudy -Sediment Odor: -Faint -Offensive                                              Tissue Perfusion, Ineffective
Color: =Light Yellow -Dark Yellow -Orange -Clots -Hematuria                                          Urinary Elimination, Impaired
                                                                                                     Urinary Elimination, Readiness
Patterns:-Incontinent -Polyuria =Nocturia -Oliguria -Urgency                                            for Enhanced
-Dysuria -Retention -Anuria -Other                                                                   Urinary Retention
Genitalia:        =No Anomalies -Discharge -Excoriation -Other
Medications R/T Bladder: =Yes -No Type                  Lasix
D. ACTIVITY/REST                                                              Requires 3 pillows     Activity Intolerance
                                                                              at night to sleep      Activity Intolerance, Risk for
Range of Motion: =Active -Passive -Limitations                                c/o difficulty
                                                                                                     Disuse Syndrome, Risk for
                                                                                                     Diversional Activity Deficient
Bed Mobility: =Self   Assist: -Partial -Total                                 sleeping in hospital
                                                                                  p g         p       at gue
                                                                                                     Fatigue
                                                                                                     Mobility, Impaired B d
                                                                                                     M bili I       i d Bed
Assistive Devices: Type                                 =N/A                                         Mobility, Impaired Physical
CPM: -Right -Left =N/A                                                                               Mobility, Impaired Wheelchair
                                                                                                     Perioperative Positioning
Joints: -Tenderness -Pain -Swelling =No abnormalities                                                   Injury, Risk for
Ordered Activity level:         Activity as Tolerated                                                Sedentary Lifestyle
                                                                                                     Sleep Deprivation
Sleep Patterns: Usual # Hours 8  # Last 24 hours 4                                                   Sleep Pattern, Disturbed
Special Needs:                  3 pillows                                                            Sleep Readiness for Enhanced
                                                                                                              Ability,
                                                                                                     Transfer Ability Impaired
Medications R/T Activity/Rest: -Yes     =No Type                                                     Walking, Impaired


                                                                -
                                                            - 14-                       NSGCAREPLAN(Sample):14:1/06
E. COMFORT                                                                  Date/Time          Related Nursing Diagnoses
                                                                            Explanation of     (Circle appropriate
                                                                            Abnormal           diagnoses)
                                                                            Assessment Factors
Pain/Discomfort: Describe:      denies chest or other pain                                     Comfort
              -
Pain Scale: (0- 10)    ∅              Last Medicated:      N/A                                 Pain, Acute
Location:                                                                                      Pain, Chronic
Quality:                                                                                       Sexual
                                                                                               Sexuality Pattern, Ineffective
-PRN Analgesic/Narcotic        -PCA     -Epidural
                                                                                               Sexual Dysfunction
Other Modalities:                                                                              Safety and Security
Medications R/T Comfort: =Yes      -No Type         Nitro- Bid
                                                         -                                     Temperature
                                                                                               Hyperthermia
F. SEXUAL                                                                                      Hypothermia
Reproductive: LMP _____ -Premenopausal -Postmenopausal =Male                                   Temperature, Risk for
Hysterectomy: =N/A -Ovaries Removed - Ovary/Ovaries Remain                                        Imbalanced Body
Breasts: =Symmetrical -Asymmetrical Describe:                                                  Thermoregulation, Ineffective
                                                                                               Skin
Self Breast/Testicle Exams: -Yes =No Freq: __________                                          Infection, Risk for
Cancer Screen: Date 2001 Test PSA Result          WNL                                          Injury, Risk for
Date _______ Test ________ Result ________ (Breast, Pap, Prostate, Colon)                      Latex Allergy Response
Sexual/Fertility Concerns:    None expressed; Widower                                          Latex Allergy Response,
-Hormone Replacement                                                                              Risk for
                                                                                               Protection, I ff ti
                                                                                               P t ti      Ineffective
Medications Related to Sexuality: -Yes =No Type
                                                                                               Skin Integrity, Impaired
II. SAFETY AND SECURITY                                                     Reddened coccyx    Skin Integrity, Impaired,
                                                                            and both heels        Ri k for
                                                                                                  Risk f
Temperature:   98.6   Route Taken: =Oral -Tympanic -Ax. -Rectal                                Tissue Integrity, Impaired
Skin:   Turgor: Location: Sternum =Elastic -Tented -Taut -Shiny                                Physical
        Temp: -Hot             =Warm        -Cool      -Dry                                    Falls, Risk for
                -Clammy        -Diaphoretic                                                    Growth, Risk for
        Color: Location: __________ =Pink       -Pale -Cyanotic                                   Disproportional
                                                                                               Mobility, Impaired Physical
                -Flushed -Jaundiced -Mottled -Other
                                                                                               Perioperative Positioning
        Bony Prominences: -Skin Intact =Reddened -Gray                                            Injury, Risk for
                -Pressure Sore Stage: _____ Location: _______________                          Trauma, Risk for
                                                                                                 au a, s o
Wound Location:                                                                                Self--Care Deficit, Bathing/
Wound: =N/A -Sutures -Staples -Drain -Dehiscence                                                  Hygiene
                                                                                               Self--Care Deficit, Dressing/
        -Evisceration -Healing by secondary intention -Other
                                                                                                  Grooming
Dressing:  =N/A -Dry/Intact -Open to Air -Stained -Saturated                                   Self--Care Deficit, Toileting
Changed:   q ___ hrs -Wet to Dry -Other Describe:                                              Surgical Recovery, Delayed
Isolation/Precautions: -Transmission Based Precautions -Additional                             Wandering
Protocols: =Braden Scale -Restraints -Special Bed -Other                                       Perception
                                                                                               Energy Field Disturbed
Physical:                                                                                      Environmental Interpretation
General   -Unassisted -Supervised       =Assisted            -Unable                              Syndrome, Impaired
Movement: -Hemiparesis/plegia -Paraparesis/plegia                                              Infant Behavior, Disorganized
          -Quadriparesis/plegia                                                                Infant Behavior, Disorganized,
                                                                                                  Risk for
Bathing/Hygiene: -Self =Assist -Total =Partial -PM Care                                        Infant Behavior, Readiness for
Oral Care:       -Self =Assist                                                                    Enhanced Organized
                                                                                               Poisonin Risk for
                                                                                               Poisoning,
Assistive Devices: Type                            =N/A                                        Self--Mutilation
Weight Bearing Status: =FWB -L PWB            -R PWB -NWB                                      Self -Mutilation,
                                                                                               Self- Mutilation, Risk for
Precautions: -Swallowing -Seizure -Spinal -Fall -Subarachnoid                                  Sensory/Perception,
                                                                                                  Disturbed (specify):
Perception:                                                                                       Visual, Kinesthetic,
Vision Deficits: -Blind (legally) =Glasses -Contacts                                               Auditory, Gustatory,
Hearing Deficits: -Deaf -HOH =Hearing Aid(s): -L -R =Bilat.                                       Tactile, Olfactory
Other:                                                                                         Suicide, Risk for
                                                                                               Unilateral Neglect
Precautions: -Danger to Self    -Danger to Others -Self Mutilation                             Violence, Risk for Other- -
             -Suicide           -Alcohol and Drug Withdrawal                                      Directed
Medications R/T Safety and Security: - Yes = No Type                                           Violence, Ri k f S lf -Directed
                                                                                               Vi l       Risk for Self- Di   d




                                                                 -
                                                             - 15-                   NSGCAREPLAN(Sample):15:1/06
Section 2: Psychosocial Assessment
Note:        It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by observing verbal and
             nonverbal behaviors and making inferences as you and the patient work toward accomplishing goals and objectives.

III. LOVE AND BELONGING                                                                                   Related Nursing Diagnoses
1. Emotional State                                                                                        Adjustment, Impaired
     a. What seems to be the client’s mood? =Normal for Age/Culture                                       Caregiver Role Strain
        -Withdrawn -Depressed -Anxious -Fearful -Uncooperative                                            Caregiver Role Strain, Risk for
        -Flat Affect -Elevated         -Euphoric -Expressive -Other                                       Communication, Impaired Verbal
2. Client’s Life Experience                                                                               Communication, Readiness for
                                                                                                            Enhanced
     a. How have previous life experiences affected the client’s perception of the
        current health problems?                                                                          Community Coping, Ineffective
                                                                                                          Community Coping, Readiness
               “My old heart is wearing out. I get this fluid every now and then. I come                    for Enhanced
                                                                                                          Delayed Development, Risk for
               here to the hospital to get rid of it.” Third admission for CHF.                           Family Coping: Compromised,
        b.     How has life changed as a result of the current health problem?                              Ineffective
                                                                                                          Family Coping: Disabled
                                                    -
               Mr. R has been confined to his home 3- 4 weeks. He needs assistance in                     Family Coping: Readiness
                                                                                                            for Enhanced
               ADLs.
                                                                                                          Family Processes, Dysfunctional:
        c.     Describe any signs or symptoms that may indicate actual/potential                            Alcoholism
               physical/emotional abuse.                                                                  Family Processes, Interrupted
                                                                                                          Family Processes, Readiness for
               No indication of physical/emotional abuse.
                                                                                                            Enhanced
                                                                                                          Growth and Development, Delayed
                                                                                                          Loneliness, Risk for
3.      Family                                                                                            Parental Role Conflict
        a. What is the client and family’s perception of the illness/admission?                           Parent/Infant/Child Attachment,
                                                                                                            Impaired, Risk for
               “I’ve had a good life. I just want to be comfortable.” Close Hispanic
                                                                                                          Parenting, Impaired
               family - 6 children.                                                                       Parenting, Impaired, Risk for
                                                                                                          Parenting, Readiness for Enhanced
        b.     What evidence indicates that family life has changed?                                      Role Performance, Ineffective
               Mr. R. lives with one of his daughters and her family.                                     Social Interaction, Impaired
                                                                                                          Social Isolation
        c.     How do family members seem to be coping? Ongoing presence of family                        Violence, Risk for
               members at bedside. No indications of ineffective coping currently.
        d.     What supportive behaviors from family/significant others are evident?
               Visits, concern, supportive family
4.      Erikson/Newman/Newman Developmental Stage:                      Very Old Age

        a.     What tasks are appropriate for this stage of development?
               Immortality vs. Extinction
        b.     How has this health problem interfered with accomplishing the
               development tasks for this client?
               Communicates confidence. Although his illness has interfered with his
               ADLs, he is coping with the physical changes of aging.

        c.     What evidence indicates negative or positive developmental resolution?
               Talks with pride over his life’s accomplishments. Voices acceptance
               of his condition.

                                                                               -
                                                                           - 16-                                       -17:1/06
                                                                                                 NSGCAREPLAN(Sample):16-
          -
IV. SELF- ESTEEM:                                                                       Related Nursing Diagnoses
1. Self- Esteem and Body Image
       -                                                                                    -Esteem
                                                                                        Self-
    a. How is the client’s self- esteem threatened by this illness/admission?
                               -                                                        Adjustment, Impaired
                                                                                        Anxiety
          Loss of independence can threaten self- esteem.
                                                -                                       Body Image Disturbed
                                                                                        Coping, Defensive
     b.   What is the client’s perception of body image and how has it changed?         Coping, Ineffective
                                                                                        Coping, Readiness for Enhanced
          “I’m glad I’m able to do what I can.”                                         Death Anxiety
     c.   What fears/concerns were expressed by the client that relate to client’s      Decisional Conflict (Specify)
          present illness?                                                              Denial, Ineffective
                                                                                        Fear
          Concern regarding his condition causing “stress” to his daughter and          Grieving, Anticipatory
                                                                                        Grieving, Dysfunctional
          her family.                                                                   Grieving, Dysfunctional, Risk for
                                                                                        Hopelessness
2.   Culture                                                                            Personal Identity, Disturbed
     a. What is the client’s ethnic background?                Hispanic                 Post--Trauma Syndrome
                                                                                        Post--Trauma Syndrome, Risk for
     b.   How does culture/language influence communication between                     Powerlessness
          client/family and healthcare workers?
                                                                                        Powerlessness, Risk for
          Hispanic culture has strong family support.                                     p -Trauma Syndrome
                                                                                        Rape-            y
                                                                                        Rape- -Trauma Syndrome, Compound
     c.   Which communication factors are relevant and why do you think so?                Reaction
          (Touch, personal space, eye contact, facial expressions, body language)       Rape- -Trauma Syndrome, Silent
                                                                                           Reaction
          Family is demonstrative in affection toward each other.                       Religiosity, Impaired
                                                                                        Religiosity, Readiness for Enhanced
     d.   Who seems to be making the healthcare decisions in the family?
                                                                                        Religiosity, Risk for Impaired
          Mr. R’s eldest daughter is the surrogate decision maker.                      Relocation Stress Syndrome
                                                                                        Relocation Stress Syndrome, Risk for
     e.   Based on your observations, what role does each family member play?               -Esteem, Chronic Low
                                                                                        Self-
                                                                                            -Esteem,
                                                                                            -Esteem Situational Low
                                                                                        Self-
          Oldest daughter is “in charge” of others.                                         -Esteem, Situational Low,
                                                                                        Self-
                                                                                           Risk for
     f.   Who is responsible for care of a sick family member at home?
                                                                                            -Mutilation
                                                                                        Self-
          Eldest daughter.                                                                  -Mutilation, Risk for
                                                                                        Self-
                                                                                        Sorrow, Chronic
     g.   What cultural practices related to hospitalization need to be considered?     Spiritual Distress
                                                                                        Spiritual Distress, Risk for
          Allow time/room for visitors.                                                 Spiritual Well--Being,
                                                                                           Readiness for Enhanced
3.   Spirituality
                                                                                            -Actualization
                                                                                        Self-
     a.
     a What spiritual/religious beliefs does the client express?                        Health Maintenance, Ineffective
                                                                                        Health Seeking Behaviors (Specify)
          Mr. R. is Catholic and attends church.                                        Home Maintenance, Impaired
     b.   What signs and symptoms if present indicate spiritual distress?               Knowledge, Deficient (Specify)
                                                                                        Knowledge, Readiness for Enhanced
          None.                                                                            (Specify)
                                                                                        Noncompliance
     c.   What spiritual practices related to hospitalization need to be considered?    Therapeutic Regimen: Community,
                                                                                           Ineffective Management of
          Allow/encourage visits from congregation members/priest.                      Therapeutic Regimen: Families,
                                                                                           Ineffective Management of
         -
V. SELF- ACTUALIZATION                                                                  Therapeutic Regimen: Management,
1. What is the client’s/family’s current level of understanding of their                   Effective
   health/illness problem?                                                              Therapeutic Regimen: Management,
                                                                                           Ineffective
     Accepts condition and understands the diagnosis.                                   Therapeutic Regimen: Management,
                                                                                           Readiness for Enhanced
2.   What type of relationship exists with healthcare providers?

     Cooperative, respectful.
Education/discharge planning: See M.E.T.H.O.D. attached.


                                                                              -
                                                                          - 17-                           -17:1/06
                                                                                    NSGCAREPLAN(Sample):16-
                    SAMPLE CARE PLAN FORM


The following pages are an example of how to write a care plan using the
accepted format for RCC. This is not a complete care plan related to JR’s
problems, but rather a brief example to show proper use of the format.




                                  -18-
                                  - -              NSGCAREPLAN(Sample):18:1/06
                                                   RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe                                      ID: 11111                     Course: N17              Date: 2/16/02
Client Initials: JR                 Admission date:         2/02/02         Age:     84            Gender: M
Medical Diagnosis:      Congestive Heart Failure

Nursing Diagnosis           Desired Outcomes           Interventions (I)-Independent      Rationale & APA Reference            Evaluation of Interventions
                                                       (C) – Collaborative (Circle)       (Use various sources)
NDX: (Problem)              Goal: (Reversal of         ASSESS:
Cardiac output,             problem)                   (May have less or more than 4)
decreased                   Adequate cardiac           N1-(I)                             R1- These s/s develop as the         E1- Denies fatigue/weakness at
                            output                                                        heart attempts to compensate for     present. No edema noted.
R/T: (etiology/factor)                                 Assess general appearance for      a decreased C.O. with resultant
(not the medical            Client will                weakness, fatigue, edema q shift   decrease in O2 supply to body’s
diagnosis):                 (list measurable           and prn                            tissues (Smeltzer & Bare, 1996,
                            outcomes; reverse                                             p. 581-2).
Altered myocardial          signs and symptoms)
contractility                                          N2-(I)                             R2- Fluid accumulation in lungs      E2- Rales decreased but
                            1. Demonstrate no
                                                                                          may occur with decreased C.O.        present in L base. R lung clear.
                            dyspnea within 24 hrs
AEB: (s/sx; defining                                   Assess lungs sounds q 4 hrs        (Carpenito, 2000, p. 14)
characteristics)            2. BP returns to
(Identify all that apply)   baseline of 145/80         N3- (I)                            R3- With decreased C.O.              E3- Apical pulse 78 bpm
                            within 24 hrs                                                 peripheral pulses may be
1. Dyspnea: c/o                                        Count apical pulse rate q 4 hrs    weakened & pulse count may be
shortness of breath         3. Lungs clear to                                             inaccurate at peripheral sites
with mild exertion.         auscultation by time of                                       (Smeltzer & Bare, 1996, p. 582).
                            discharge
2. Blood pressure,                                     N4- (I)                            R4- Assessment of respiratory        E4- RR 14-18
increased: 176/94           Evaluation of                                                 rate can reveal symptoms r/t fluid
                            Outcomes (address          Count respiratory rate q 4 hrs     overload (Sparks & Taylor, 2004,
3. Rales in left base of    each outcome)                                                 p. 59).
lung
                            1.Dyspnea decreased        N5- (I)                            R5- To ascertain response to         E5- BP 154/96; decreased from
*If ‘risk for’ identify     but still present with                                        therapy-increased BP is a sign of    176/94
what the client would       exertion                   Measure BP q 4 hours               stress on the system (Smeltzer &
exhibit (note there                                                                       Bare, p. 582)
are no signs and            2. BP still elevated
symptoms for ‘risk          (154/96)                   N6- (I)                            R6- Peripheral circulation maybe     E6- Radial and dorsalis pedal
for’ problems):                                                                           be impaired with decreased C.O.      pulses 2+, others 3+
                            3.Rales diminished but     Assess peripheral pulses q 4 hrs   (Smeltzer & Bare, p. 582)
                            still present




                                                                                   -19-                           NSGCAREPLAN(Sample):19-22:1/06
                                                 RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe                                    ID: 11111                     Course: N17              Date: 2/16/02
Client Initials: JR               Admission date:         2/02/02        Age:    84              Gender: M
Medical Diagnosis:    Congestive Heart Failure

Nursing Diagnosis         Desired Outcomes           Interventions (I)-Independent      Rationale & APA Reference             Evaluation of Interventions
                                                     (C) – Collaborative (Circle)       (Use various sources)
                          Evaluation of Goal:        ACTIVITIES:
                          (circle one)               (May have less or more than 4)
                                                     N1- (I)                            R1- These anatomical positions        E1- Positions self with HOB
                          Goal met                                                      facilitate ease of breathing &        elevated 15 degress. Sat in chair
                                                     Elevate head of bed 15-45          promote rest (Smeltzer & Bare,        X30 min twice during day.
                          Goal not met               degrees. Use cardiac chair when    2000, p. 583)
                                                     OOB
                          Goal partially met

                          Continuation of plan:
                          (circle one)               N2- (I)                            R2- Client may tire easily or         E2- Ambulated to BR without
                                                                                        become dyspneic-need to               respiratory distress. Partial bed
                          Continue plan of care      Assist as needed with ambulation   conserve energy (Smeltzer &           bath given instead of shower.
                                                     and with shower                    Bare, 2000, p. 621)
                          Discontinue plan of
                          care

                          Revise plan of care
                                                     N3- (I)                            R3- Accurate I & O is essential for   E3- Intake 400cc this shift,
                                                                                        monitoring for potential fluid        output 850cc.
                                                     Measure and document intake &      overload (Sparks & Taylor, 2004,
                                                     output q 4 hrs & prn.              p. 42)




                                                     N4- (I) (C)                        R4-                                   E4-




                                                                                -20-                            NSGCAREPLAN(Sample):19-22:1/06
                                                 RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe                                    ID: 11111                    Course: N17          Date: 2/16/02
Client Initials: JR               Admission date:         2/02/02        Age:    84           Gender: M
Medical Diagnosis:    Congestive Heart Failure

Nursing Diagnosis         Desired Outcomes           Interventions (I)-Independent     Rationale & APA Reference      Evaluation of Interventions
                                                     (C) – Collaborative (Circle)      (Use various sources)
                                                     MEDICATIONS:                                                     Evaluate TACTIS of each
                                                     (May have less or more than 4)                                   Medication.

                                                     N1- (I)                           R1- SEE TACTIS on medication   E1- Med held. Digoxin level 2.6.
                                                                                       sheet                          M.D. called.
                                                     Give Nitro Bid 2.5 mg po QD as
                                                     ordered @0900 after checking
                                                     Digoxin level

                                                     N2- (I)                           R2- SEE TACTIS on medication   E2-
                                                                                       sheet                          T – BP remains elevated 154/96;
                                                     Give Lasix 40 mg p.o. BID after                                  No edema noted.
                                                     checking K+ level.                                               A – Na+ and Cl- reabsorption
                                                                                                                      inhibited.
                                                                                                                      C – No hypersensitivity or other
                                                                                                                      contraindications noted.
                                                                                                                      T – K+ 3.3 K-rider given
                                                                                                                      I – Assess for dehydration – No
                                                                                                                      S/S.
                                                                                                                      S – 40 mg safe dose (20-80
                                                                                                                      mg/day safe).




                                                                                -21-                       NSGCAREPLAN(Sample):19-22:1/06
                                                 RCC Nursing Education Programs Nursing Care Plan
Student Name: Jane Doe                                    ID: 11111                    Course: N17             Date: 2/16/02
Client Initials: JR               Admission date:         2/02/02        Age:    84            Gender: M
Medical Diagnosis:    Congestive Heart Failure

Nursing Diagnosis         Desired Outcomes           Interventions (I)-Independent     Rationale & APA Reference           Evaluation of Interventions
                                                     (C) – Collaborative (Circle)      (Use various sources)
                                                     TEACHING:                         May use “See Method” only if you    May use “See Method” only if
                                                     (May have less or more than 4)    include the teaching point on the   you include the teaching point
                                                                                       Method.                             on the Method.


                                                     N1- (I) (C)                       R1- See METHOD                      E1- See METHOD

                                                     Teach patient about medications
                                                     and activity restrictions




                                                     N2- (I) (C)                       R2-                                 E2-




                                                     N3- (I) (C)                       R3-                                 E3-




                                                     N4- (I) (C)                       R4-                                 E4-




                                                                                -22-                          NSGCAREPLAN(Sample):19-22:1/06
                       M.E.T.H.O.D. Daily Teaching Plan and Evaluation

PATIENT INITIALS:            J.R.

LEARNERS PRESENT (circle):           Client X     Family            Sig.Other      Other Daughter

MEDICAL DIAGNOSES: CHF; CAD

TECHNIQUES:           Discussion     Q/A     Demos          Handout(s)      Other ______________

   Date
Complete                              Content                                      Evaluation
& Initials
06/23/02     M (Medications):                                          M = Discussed each
             Lasix (Furosemide). Decreases swelling and blood          medication. Knew the
JD           pressure by increasing the amount of urine. Expect        purpose of each drug. Was
             increased frequency and volume of urine. Report           checking his own blood
             irregular heartbeat, changes in muscle strength, tremor,  pressure each week at
             and muscle cramps, change in mental status, fullness,     home, using cuff he bought
             ringing/roaring in ears. Eat foods high in potassium such
                                                                       at the drugstore. Needs to
             as whole grains (cereals), legumes, meat, bananas,
             apricots, orange juice, potatoes, and raisins. Avoid      review side effects and
             sun/sunlamps. Take with breakfast to avoid GI upset.      precautions of both lasix
             Digoxin (Lanoxin). Used to treat CHF. Taking too          and digoxin. Given written
             much can result in GI disturbances, changes in mental     patient drug information.
             status and vision. Report the following signs/ symptoms
             to your doctor: Nausea, vomiting, lack of appetite,
             fatigue, headache, depression, weakness, drowsiness,
             confusion, nightmares, facial pain, personality changes,
             sensitivity to light, light flashes, halos around bright
             objects, yellow or green color perception. Take pulse
             rate for one minute before dose and call doctor if pulse is
             below 60 before taking medication. Don’t increase or
             skip doses. Don’t take over the counter medications
             without talking to MD. Report for follow-up visits with
             your doctor to monitor lab values.
06/23/02     E (Environment):                                              E = He lives with his eldest
             Your eldest daughter will provide help with activities of     daughter who helps him
JD           daily living in the home. She will transport you to follow-   with meals, medication
             up appointments. It is important to take steps to prevent     administration, getting to
             falls: use of a 3-point cane for stability with ambulation;   appointments, etc.
             removing objects like throw rugs, cords that may cause        Verbalizes understanding of
             fall; pausing before standing and again before walking to
                                                                           fall prevention and activity
             prevent drop in blood pressure. The “life line” allows you
             to access 911 for emergency help. You may resume              level. Understands
             activities as tolerated and you have a follow-up              appointment date and time
             appointment with the doctor in 1 week.                        for follow-up.




                                              -23-              NSGCAREPLAN(Sample):23-24:1/06
06/23/02     T (Treatments):                                          T = Daughter was able to
             Apply A & D ointment to reddened coccyx and heels        demonstrate proper
JD           three times a day. Keep pressure off of these areas by   positioning. Client and
             keeping off of back and elevating heels off of bed. Keep daughter able to describe
             skin clean and dry. Report any changes in skin condition skin care.
             to doctor. (i.e. open areas, drainage, elevated temp.)
6/23/02      H (Health knowledge of disease):                            H = Verbalizes signs and
             Lasix can cause a loss of potassium. It is important to     symptoms of electrolyte
JD           eat foods high in potassium and to have regular blood       imbalance and digoxin
             levels drawn to make sure potassium level stays normal.     toxicity. He stated what
             Monitoring the pulse rate before taking digoxin is          foods are high in potassium
             important because this medicine can cause the pulse to      and what foods to avoid
             drop. Call the doctor if pulse rate is below 60 beats per
                                                                         that are high in sodium.
             minute. New signs and symptoms should be reported to
             the physician, because they may indicate electrolyte        Demonstrated how to
             imbalance &/or digoxin toxicity. Sodium causes water        assess pulse rate and when
             retention so it is important to limit sodium intake by      to call the doctor.
             eating a no added salt diet. Be careful to check labels
             for hidden salt content.

6/23/02      O (Outpatient/inpatient referrals): (include resources      O = Given information for
             such as websites and organizations):                        national and regional
JD           American Heart Association                                  resources related to heart
             www.americanheart.org                                       disease. Referrals to VNA,
                                                                         dietician and Meals on
             Visiting Nurses’ Association for F/U skin assessment.       wheels completed.
             Referral made to outpatient dietician for diet planning.

             Meals on Wheels.
6/23/02      D: (Diet):                                                  D = Diet teaching
             Do not add salt to your diet. Eat foods high in potassium   completed regarding low
JD           such as bananas. We will arrange for you to meet with       salt, high potassium diet.
             the dietician.                                              F/U with dietician as
                                                                         outpatient arranged. Client
                                                                         and daughter state they
                                                                         understand diet. . Meals on
                                                                         wheels contacted.


Schuster, P. (2000). The key to the therapeutic relationship. Philadelphia: FA Davis.
Schuster, P. (2002). Concept Mapping: A critical thinking approach to care planning. Philadelphia:
       FA Davis.




                                              -24-              NSGCAREPLAN(Sample):23-24:1/06
                            Directions for Using METHOD Daily Teaching Plan
General Guidelines
1.      Write the instructions for the client. These are not guidelines for the nurse who will be doing the teaching.
2.      Complete all sections, recognizing that each section may not be taught in one session.
3.      Complete one METHOD per client.
4.      In the Evaluation column, either describe the client response to the teaching or indicate the reason the
        teaching did not take place.
5.      The content must be stated in simple, specific terms, so the client can understand the instructions.
6.      Assessment forms the basis for teaching in each area, and is therefore always the first step.
7.      Use learning principles when preparing the teaching plan. This would include such things as selecting the
        right time for the teaching and building on the client’s prior knowledge of the subject.

Environment
1.      Definition: Factors that affect the client’s health care in the facility or home.
2.      Examples
        a.      safety
        b.      activity order, including restrictions
        c.      availability of transportation
        d.      psychosocial issues
        e.      finances
        f.      cleanliness
3.      Directions
        a.      Identify pertinent environmental factors assessed by the nurse.
        b.      Describe teaching needed to help the client modify the environment.

Treatments
1.      If the client is in a facility: Teach the purpose of the treatment(s) and how the client can assist when the
        treatment(s) is/are performed.
2.      If the client is at home: Provide simple directions about how to perform the procedure, including
        technique, safety measures, and supplies/equipment needed.

Health Knowledge of Disease
1.      Assess the client’s knowledge about the disease and provide information essential for managing the
        condition.
2.      Provide web sites for obtaining information about the disease.
3.      Teach S/S of complications. Examples
        a.      wound: S/S infection
        b.      heart: S/S of heart failure
4.      Teach when to contact the primary healthcare provider and how to do that.

Outpatient/Inpatient Referrals: Instructions are included on the form.

Diet
1.      Include purpose and cultural adaptations.
2.      Consider finances and who will be shopping for and preparing the food.




                                                      -25-                  NSGCAREPLAN(Sample):25:1/06

				
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