Name Sarah A. Fabry




B. Developmental Stage

Pt. Initials       Room      


Stage According to Erickson. Give rationale for choice.

Age       Sex       Ht       Wt       Code Status

Health State
Past medical-surgical history with dates:

Date of Admit:      


Resident's Description of why they are at the facility:




Sociocultural Orientation

Cultural/Ethnic Background:      


Any special rituals/customs the resident does?      


Patterns of living:      

Family system elements:      
Huggins 1.23.11 NUR130/Care Plan


Any transcultural aspects to be considered?      
Page 1

E.23. Health Care Systems Elements Admitting Diagnosis:       Current Diagnosis:       Surgery (include date & briefly describe):       Treatments/Procedures: Ordered for assigned resident       Huggins 1.11 NUR130/Care Plan Page 2 .

11 NUR130/Care Plan Page 3 .23.Huggins 1.

23.11 NUR130/Care ____Plan Page 4 Assessment ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______________________ .Assessment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___ Assessment ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ _____ Assessment _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _ Medical DX Assessment _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Huggins 1.

CONCEPT MAP Pathophysiology Risk Factors Medical Diagnosis Clinical Manifestations Complications Treatment Nursing Diagnosis Huggins 1.23.11 NUR130/Care Plan Page 5 .

23.11 NUR130/Care Plan HEMOCCULT Sites _______ Results ________ Page 6 GASTROCCULT .MOST RECENT LAB RESULTS (Circle Abnormal Results) HEMATOLOGY CHEMISTRY URINALYSIS CBC Glucose Color WBC BUN Clarity RBC Creatinine Spec. Lymph Phosphate Urobilinogen Monos Bilirubin (total) WBC Eosin Low density lipids (LDL) RBC Baso High density lipids (HDL) Epith Cells Other Total Protein Bacteria RBC Indices Albumin Leukocytes MCV Uric Acid Nitrites MCH Alk Phos MC HC CARDIAC ENZYMES COAGULATION LDH (LD) ACCU CHECK PT CPK (CK) Time INR Digoxin Level PTT SGOT (AST) Result Cholesterol PULSE OX Triglycerides ABG’s PH OTHER TESTS PCO2 CXR P O2 Other X-rays/MRI BASE Endoscopy/Colonoscopy SAT EKG Huggins 1. Gravity Hgb Sodium pH Hct Potassium Protein Platelets Chloride Glucose Differential CO2 Content Ketones Polyps Amylase Bilirubin Bands Calcium Occult Bl.

classification.ULTRASOUNDS E. dosage.23. and rationale for the meds you gave and the prn medications that were prescribed for this patient. duration & side effects for each med listed.11 NUR130/Care Plan Classification Rationale (Why is this patient getting this med?) Page 7 . Medication Dosage Huggins 1. Sites ________Results_________ Health Care Systems Elements (Continued) Medications: List medication. Submit med cards with action.

11 NUR130/Care Plan Page 8 .e.UNIVERSAL SELF-CARE DEFICITS (Circle the abnormal areas) Oxygenation/Circulation Respiration O2 sat Lung sounds (posterior/anterior) (upper/lower lobes) Cough Productive Temperature Regulation Hygiene Temperature Personal hygiene pattern Perspiration Ability to dress self Resident perception of temperature Skin assessment Nutrition: Food and Water Non-productive Color Temperature Height/Weight Chest symmetry Moist/dry Respiratory Aids/Treatments Current diet Bruising/discoloration Open areas/where Attitude towards eating Cardiovascular status Scarring Heart sounds Aids to eating Wound assessment Hydration/TPN/EN Dressing assessment Skin Color Skin temperature Cap refill Turgor Edema Upper extremities Teeth/Dentures Edema Lower extremities Braeden scale score Aids to circulation (compression stockings. day two-Green Abnormal areas should be highlighted PART A: ASSESSMENT . day one . ect) Abdominal Assessment Condition of Teeth Bowel sounds Pulse Radial R Pedal L R L Distension Blood pressure (sitting/standing/lying) Pain R L PART A: ASSESSMENT UNIVERSAL SELF CARE DEFICITS (Circle the abnormal areas) Huggins 1.Use a separate color of ink for each day of assessment data i.Blue.23. FOB elevated.

11 NUR130/Care Plan Page 9 Other List assessment data here which doesn't seem appropriate in the other areas.Rest/Activity And Sleep Solitude & Social Interaction Sleep patterns Socialization/communication Relaxation techniques Solitude Sense of Normalcy Self esteem Hearing Aids Glasses Activity patterns Stressors Support systems Mobility Protection From Hazards Aids to mobility (including sensory alterations) Level of Consciousness Mobility restrictions Orientation: Person. time Elimination/Excrements Bowel pattern Last BM Urinary pattern Color of urine Any sediment/blood present Incontinent products Environmental hazards Sensory alterations Fine motor skills: Gross motor skills Pupilaary reflexes Accommodation Pain with elimination Foley catheter (tubing patent) Huggins 1. place. .23.

PART B: LIST OF NURSING DIAGNOSES Self Care Deficits are highlighted in your assessment.11 NUR130/Care Plan Page 10 . Indicate the order of priority on day 1 and day 2 of your care. List as many nursing diagnoses based on these deficits as are appropriate. Day 1 Day 2 Nursing Diagnoses Day 1 Day 2 Nursing Diagnoses P       P       R/T       R/T       M/B       M/B       P       P       R/T       R/T       M/B       M/B       P       P       R/T       R/T       M/B       M/B       P       P       R/T       R/T       M/B       M/B       Huggins 1.23.

Huggins 1. Measurable with time frame. Interventions/Rationale Minimum of 2 interventions per goal. and #3 from your list of Nursing Diagnoses for day 1 of your care.) Nursing Diagnoses Goal/Expected Outcomes 1 short and 1 long term goal According to NANDA. 4. Resident Response to Intervention Goal/Outcome Evaluation 1 outcome per goal 1 response for each intervention Evaluate effectiveness of each intervention. Problem Statement The expected change. Minimum of five. Actions. Long term Long Term 4. Refer to problem statement in Nursing Diagnosis The patient will……. Short tem 1. .. Short Term . 1. why not? What would you do differently next time? Is the plan continued or discontinued? Your signature and date The nurse will (intervention) in order to (rationale). Was the goal/expected outcome accomplished? If not.PART B: NURSING CARE PLAN (Develop priority #1. 3. . 2. 5. . what is nursing to do and why? Individualized and specific to this patient. #2.23. As Manifest By 3. 5.11 NUR130/Care Plan Page 11 . Related to (Etiology/Cause) 2. Ideas designed to change etiology Rationale should include author and page if appropriate.

23.Generic: Brand: Action (Classification) Uses: Route and dose: Side effects: Contraindications: Precautions: O-P-D: Elimination: Nursing Considerations: Lab Consideration: Generic: Brand: Action (Classification) Uses: Route and dose: Huggins 1.11 NUR130/Care Plan Page 12 .

Side effects: Contraindications: Precautions: O-P-D: Elimination: Nursing Considerations: Lab Consideration: Huggins 1.11 NUR130/Care Plan Page 13 .23.

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