NURSING CARE PLAN - DOC - DOC by xscape

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									                            NURSING CARE PLAN

Student Name:
Dates of Pt. Care:
Facility:
Unit & Room:

DATA COLLECTION

Admission Date:
Admitting Diagnosis:
Patient Initials:
Age:
Sex:
Occupation:
Allergies:
Other Miscellaneous Diagnosis:
Past Medical History:

Day 1
Pain Level: T:       HR:   RR:   B/P:   Braden Score:   WT:

Day 2
Pain Level: T:       HR:   RR:   B/P:   Braden Score:   WT:



Chief complaint: (10)
Family Health History: (5)
Surgeries / Procedures / Significant tests: (5)
Pathophysiology of Admitting Diagnosis: (15)
Lab Values Normal & Abnormal: (10)


CBC
Wbc (4.0-11.0)TH/UL
Rbc (4.60-6.20) Mil/UL
Hgb (13.5-17.5) GM/DL
Hct (40.0-54.0)%
Mcv (80.0-100.0)FL
Mch (27.0-34.0)PG
Mchc (32.0-63.0)GM/DL
Plt (130.0-400.0)
Neu% (42.0-72.0)
Lymph% (17.0-45.0)
Monocle% (3.0-10.0)
Eosinophil% (1.0-10.0)
Basophil% (0.0-5.0)
Neut Abs Cnt (1.6-83.00)x1000
Lymph Abs Cnt (1.0-4.5)x1000
Mono Abs Cnt (0.10-0.55)x1000
Eos Abs Cnt (0.0-0.55)x1000
Baso Abs Cnt (0.0-0.20)x1000

CHEM
Na+ (136-144)MMDL/L
K+ (3.6-5.1)MMOL/L
CL- (101-111)MMOL/L
CO2 (22-32)MMOL/L
Anion Gap (4-16)MMOL/L
Glucose Random (74-118)MG/DL
BUN (8-20)MG/DL
Creatinine (0.5-1.2)MG/DL
eGFR
Bun/Creat Ratio (6-27)
Protein Total (6.1-7.9)GM/DL
Albumin (3.5-4.8)GM/DL
Calcium (8.5-10.4)MG/DL
Alk P-Tase (38-126)IU/L
SGOT (AST) (15-41)IU/L
SGPT (ALT) (3-36)IU/L
Total Bili (0.4-2.0)MG/DL

Physical Assessment: (29)
General Appearance: (2)
Neurological Status: (3)
EENT: (3)
Cardiovascular: (3)
Respiratory: (3)
Gastrointestinal: (3)
Genitourinary: (3)
Musculoskeletal: (2)
Integumentary: (2)
Other Misc. Concerns or Issues: (5)




    Trade / Generic              Basic Drug      Admin. Concerns &
        Name                    Classification      Side Effects
Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic




   Trade / Generic     Basic Drug      Admin. Concerns &
       Name           Classification      Side Effects
Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic


Trade     Dose/Freq

Generic




    PATIENT         NURSING      SCIENTIFIC     EVALUATIONS
   PROBLEM       INTERVENTION   RATIONALS for    of NURSING
                                       NSG       INTERVENTIONS
                                INTERVENTIONS
NANDA DX: (2)   1. (2)          1. (2)           1. (1)

                2. (2)          2. (2)           2. (1)
R/T: (1)
                3. (2)          3. (2)           3. (1)

AEB: (2)        4. (2)          4. (2)           4. (1)

                5. (2)          5. (2)           5. (1)

                6. (2)          6. (2)           6. (1)




    PATIENT         NURSING         SCIENTIFIC    EVALUATIONS
   PROBLEM       INTERVENTION    RATIONALS for     of NURSING
                                       NSG       INTERVENTIONS
                                INTERVENTIONS
NANDA DX: (2)   1. (2)          1. (2)           1. (1)

                2. (2)          2. (2)           2. (1)
R/T: (1)
                3. (2)          3. (2)           3. (1)

AEB: (2)        4. (2)          4. (2)           4. (1)

                5. (2)          5. (2)           5. (1)

                6. (2)          6. (2)           6. (1)

								
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