Posted: February 26th, 2023

NURSING DIAGNOSIS CARE PLAN

School of Nursing Name: Date: Care Plan # Nursing Care Plan- Basic Conditioning Factors Patient identifiers: Age: Gender: Ht: Wt. Code Status: Isolation: Development Stage (Erikson): Give the stage and rationale for your evaluation Health Status Date of admission: Activity level: Diet: Fall risk (indicate reason): Client’s description of health status: Allergies: (include type of reaction) Reason for admission: Past medical history that relates to admission: Socio-cultural Orientation Religious, Cultural and Ethnic background with current practices: Socialization: Family system (support system): Spiritual: Occupation (across the lifespan): Patterns of living (define past and current): Barriers to independent living: ALLERGIES: Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following: 1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication? Medication Classification Dosage & Route Rationale Possible Negative Outcomes CONCEPT MAP Pathophysiology – (to the cellular level) Medical Diagnosis Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies). What symptoms does your client present with? Complications Treatment (Medical, medications, intervention and supportive) Risk Factors (chemical, environmental, psychological, physiological, and genetic) Nursing Diagnosis Problem statement (NANDA diagnosis): Related to (What is happening in the body to cause the issue?): As evidenced by (Specific symptoms): . LAB VALUES AND INTERPRETETION LAB Range Value Value MEANING (If WDL then explain the possible reason for the lab) LAB Range Value Value MEANING HEMATOLOGY CHEMISTRY CBC Glucose WBC BUN RBC Cr HGB GFR HCT Na PLATLETS K Diff: CO2 Polys Ca Bands Phos Lymph Amylase Mono Lipase Eosin Uric Acid GBC indices Protein MCV Albumin MCH Cl MCHC Enzymes COAGs LDH PT CPK INR SGOT PTT SGPT ABGs (V or A) Troponin I PH Myoglobin PCO2 PO2 Cholesterol BASE EX: SAT: URINALYSIS Range Value Value Meaning Others not listed: Findings Meaning Color Gast occult Clarity Hemoccult Sp. Gravity pH EKG Protein Glucose CT Scan Ketones Bilirubin Occ. Blood MRI or MRA Urobilinogen WBC RBC Epithelia Ultrasound WBC RBC Epith Cell Bacteria Hyaline Cast Gran Cast Bedside Procedures: Leukocytes Nitrite ACCUCHECKS Additional information: Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment findings) Vital Signs Time: Time: Oxygenation/ Circulation Intake: SpO2 1. 2. 3. Accu-check 1. 2. 3. 4. Output: Cardiovascular Assessment Specialty devices: Teaching needs: Heart Sounds: Skin Temp/Moisture/Color: Edema: JVD: Peripheral Pulses: Pain assessment (OPQRST) Rating: Location: Respiratory Assessment Special devices: Oxygen: Teaching Needs: Lung sounds: Anterior: Posterior: Respiratory effort: Respiratory pattern: Reg/Irreg Cough: Respiratory treatment: Medication(s): Frequency: Rationale for use: Neurological Assessment: Assistive devices : Teaching Needs: Level of Consciousness: Alert / Verbal / Pain / Unresponsive Orientation: Person / Place / Time / Events Fine motor function: Gross motor functioning: Sleep patterns (During admission): Sleep patterns (at home): GI Assessment: LBM (include description): Teaching needs: Abdominal Assessment: (observe - auscultate - palpate) Alteration in eating or elimination patterns: Nutrition Metabolic Assessment: % diet taken: Alternative nutritional methods: GU assessment: Teaching needs: Last void: Due to void: Alternative urinary elimination method: (if urinary catheter in place, when inserted) Bladder scan Assessment of urinary patterns: Urine assessment (color odor concentration etc.) LMP Integumentary Assessment: Teaching needs: Color/ Mucous membranes Hydration: Wound Care: Condition of skin: Nutritional Assessment: Teaching needs: Diet: Eating patterns: Insulin administration: Treatment of hypoglycemia: Alternative feeding patterns: IV Therapy IV fluids infusing: Rate: Tubing dated? IV Site Assessment: Location Date of insertion: Change (site or dressing) IV removal: Reason for removal: Additional information: REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS THE SPECIFIC RESPONSE. PLAN OF CARE: Use your top “2” priorities NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation NRS DX: Problem Statement: R/T: (What is the cause of the symptom) Manifested by: (Specific symptoms) Short term goal : Create a SMART goal that relates to hospital stay. Long term goal : Create a SMART goal that is appropriate for discharge. This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes) Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch) Was it met? Not met? Partially met? If only partially met, what adjustments need to be made? NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation NRS DX: Problem Statement: R/T: (What is the cause of the symptom?) Manifested by: (specific symptoms) Short term goal: Create a SMART goal that relates to hospital stay. Long term goal: Create a SMART goal that is appropriate for discharge. This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes) Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch) Was it met? Not met? Partially met? If only partially met, what adjustments need to be made? Nursing Care Plan 2

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