CARE PLAN ASSIGNMENT
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
Student Name:
Week:
Dates of Care:
Patient Initials
Sex
Age
Room
Admitting Date
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Shortness of Breath, Chest pain
Attending physician/Treatment team:
Consults:
Present Diagnosis: (Why patient is currently in the hospital)
Arrhythmia/dysrhythmia (Heart failure)
Atrial fibrillation with rapid ventricular response (HCC)
ER Management: (if applicable)
Allergies: Bactrim (Sulfamethoxazole trimethoprim) iodine rash
Code Status: Full
Isolation: (type and reason)
None
Admission Height:
Admission Weight:
Arm Band Location (colors & reasons)
Communication needs: (verbal, nonverbal, barriers, languages)
Verbal
Past Medical History: (pertinent & how managed)
Melanoma (HCC)
Cancer
COPD
Genital herpes
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)
Time
0817
T
97
P
100
R
18
B/P
129/56
Time
1320
T
97.7
P
122
R
18
B/P
122/89
GI:
Diet:
Swallow precautions:
Tube feedings:
NG / G tube:
Blood Glucose: (time & date)
Last bowel movement: (time & date)
Pertinent Labs/Test:
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Respiratory:
02 modalities:
02 Saturation:
Suction:
Resp Rx’s:
Trach:
Chest Tubes:
Pertinent Labs/Test:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB)
Neurosensory:
Neuro checks:
Alert & Orientated: Yes
Follows commands: Yes
Speech Comprehensible: Yes
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Cardiovascular:
Telemetry:
Pacemaker/IAD:
DVT Prevention:
Daily Weights:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
Musculoskeletal:
Activity:
Traction:
Casts/Slings:
Pertinent Labs/Test:
Assessments/Interventions:
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
Renal:
Catheter (indwelling/external):
CBI:
Dialysis:
A/V access:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)
Skin:
Braden Score:
Pertinent Labs/Test:
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
Pain:
Pain score:
Assessments/Interventions:
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
Vascular Access: (IV site)
Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge)
Post-operative /procedural:
Assessments/Interventions:
(immediate post procedure care)
Safety:
Call light:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Sitter use:
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)
Advance Directives/Ethical considerations:
DPOA:
Hospice:
Pertinent Data (Labs, X-rays, Etc.)
Results
Normal Lab Values
Significance to your patient
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
Platelets
RDW
MPV
PT
INR
APTT
Glucose
BUN
Creatinine
Sodium
Potassium
Cloride
Calcium
T Protein
Albumin
SGOT
SGPT
Alk Phos
Magnesium
Amylase
Lipase
CPK
LDH
Cholestrol
CK
CK-MB
Troponin I
Myoglobin
LDI
Urinalysis
Color
Character
Spec. Grav.
pH
Protein
Glucose
Acetone
Bilirubin
Blood
Nitr
Urobili
RBC
WBC
Epithelium
Urine Culture
Chest X-ray
MRI
CT Scan
Others test:
Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)
Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:
Current overall plan of care: (A short statement that summarizes the anticipated plan of care)
Discharge plans and needs:
Teaching needs:(Disease process, medications, safety, style, barriers)
Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.
ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article.
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.
Priority
Nursing Diagnosis
Related to
As Evidence By
Rationale (reason for priority)
1
2
3
4
5
Medications
Classification
Dose
Route
Freq
Purpose/Mechanism of Action
Significant Side Effects / Adverse Reactions
Nursing Implications
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)
Patient Goal(s)
Statement of purpose for the patient to achieve
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)
Patient Goal(s)
Statement of purpose for the patient to achieve
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
PAGE
1
Rubric Name: Care Plan Rubric
This table lists criteria and criteria group names in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. You can give feedback on each criterion by tabbing to the add feedback buttons in the table.Criteria
Good
4 points
1. Patient information and health assessment: Complete patient demographics, health assessment and interventions
All of the demographic section is completed, all areas of the health assessment is completed interventions are identified for the health assessment data that is identified.
2. Pertinent Diagnostic Data: Identify abnormal diagnostics, state significance for this patient.
Identified all of the abnormal diagnostics and stated the significance for this patient.
3. Number of Nursing Diagnoses: Provided 5 correct nursing diagnoses for the patient based on the patient health assessment, history, labs, and pathophysiology.
Identified 5 nursing diagnoses for the patient that are correct based on the patient assessment, history and data
4. Pathophysiology: Disease process description including “Signs and Symptoms” as well as APA references cited
Explanation of pathophysiology chosen; given with accurate details related to client’s symptoms and current illness. APA references noted
5. Pharmacology: Complete and accurate description of current medication list that includes description of medications, side effects as well as nursing considerations specific to the patient
List all MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug
6. Nursing Diagnosis: (Includes all 5 Dx) Reflects the primary diagnosis and is appropriate for patient scenario as well as priority level. Expressed in acceptable NANDA format. Also includes all parts stem, R/T, and AEB
Diagnosis is appropriate for patient/priority level. NANDA approved. Diagnosis also includes all parts and information
7. Assessment: Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis
Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx
8. Patient Outcomes Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome
Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria
9. Interventions: Include interventions or nursing actions that directly relate to the patient’s goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal
Intervention portion contains an adequate number of interventions to help the patient/family meet their goal. The interventions are specific in action and frequency, and are also listed with rationales.
10. Evaluation: Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If is not met or partially met, plan of care is revised or continued and a new evaluation date
Evaluation portion does contain data that is listed as criteria within the goal statement. Does describe the outcome as met, partially met, or not met, includes revision of plan of care, or new evaluation date/time.
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