๓๗

วิทยาลัยพยาบาลบรมราชชนนี สรรพสิทธิประสงค์
รายงานการวางแผนการพยาบาล (Nursing Care Plan)
วิชา ปฏิบัติการพยาบาลผู้ใหญ่ ๑

นางสารว ศ ? สระแ
ชื่อ-สกุล นักศึกษา.............................................เลขที ่..........ชั้นปี..........รุ่น...........หลั
25 2 5 กสูตร พยาบาลศาสตรบัณฑิต
4 มภา
วันที่.............................................หอผู
I6 '% ·อโฮป
้ป่วย................................................................เตียง..............................................
ต ⑥

ประวัติส่วนตัว
ผู้รับบริการเพศ....................................................อายุ
ชาย โส
...........ปี สถานภาพสมรส..........................................................
2.

ไทย
เชื้อชาติ...........ศาสนา...............ระดั
พ ก ัลงศึกษา ดมศึ
บการศึกษา..............................อาชี
ก ก
พ.......................รายได้ ........................บาท/เดือน
-

ที่อยู่ปัจจุบนั อาเภอ........................................จังหวัด..........................................................................................................
⑤
มภา
รับไว้ในโรงพยาบาลวันที่.....................................เดือน.....................................พ.ศ..................เวลา...................................
2567 15. 40 ป

4
มภา
รับไว้ในความดูแลของนักศึกษาวันที่......................เดือน.....................................พ.ศ..................เวลา................................
2567 16.30 น

ประวัติครอบครัว
สถานภาพในครอบครัว ( ) หัวหน้าครอบครัว ( ) สมาชิก :

บุคคลในความรับผิดชอบ.................คน -

า นไม ้ น ี ยว ใ
สภาพแวดล้อม.......................................................................................................................................................................
เด

สุขภาพอนามัย.......................................................................................................................................................................
ประวัติการเจ็บป่วย
แขนขวายก ไม่ ้น Motor power grade -6 เเ ออน อนมาโรงพยาบาล มาตามนัดเพอ า ด Nerv
อาการสาคัญ.........................................................................................................................................................................
.1

ประวัติการเจ็บป่วยปัจจุบัน
6 เ อ น ่อนมา ขับ M2 จ้ม ไม่สลบ จ เเหต ุการ ์ไ ไ Nofr
่ actur eเ บ เวณแข นข
ว วาเปป กษา ว ่โรงพยาบา าล ม.อ
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ง Refer าโรงพยาบาลสรรพ ท ประสง ตรวจ Electromyograp
phy ( EM. G ) พบเ นปประสาทบาดเ บ Motor power grade ปวดเป็
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rม

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ประวัติการเจ็บป่วยในอดีต
อ 1 · ังกแแ วเเคย าต ด
-เ...................................................................................................................................................................................................
ป

ิเด ประะ แ พ้ยา แพ

-ปฏ
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เสชโรคประจ
-ป...................................................................................................................................................................................................
เสมกาารเ บป่วยในครอ
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-ป
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คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

นั
กุ
กุ
บ้
ื่
ก่
ตั
ริ
ตั
จึ
ี่
มี
ตั
ผ่
ติ
ดื
วั
ขึ
ำ
ณ์
ค์
ร่
ที
ิ่
ล้
รี
จ็
มื่
ริ
จ็
กุ
ผ่
ม่
ดื
จ็
ชั้
ศึ
ฏิ
อุ
รั
ฏิ
พั
พั
ด้
ส้
ำ
ำ
พั
สิ
ธิ
 ๓๘

สรุปการประเมินสภาพตามแบบแผนสุขภาพ (11 แบบแผนสุขภาพของกอร์ดอน) ที่มีการเบี่ยงเบนพร้อมข้อมูล

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การวินิจฉัยโรคแรกรับ วันที่ .............................................
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การวินิจฉัยโรคปัจจุบัน วันที่ ............................................

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การรักษาเฉพาะ/การผ่าตัด (พร้อมเหตุผลของการรักษา/การผ่าตัด)
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อ้างอิง:................................................................................................................................................................

การรักษาที่ยังได้รบั ในปัจจุบัน (วันที่ .....................)

Date Order for one day Order for continuous

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๓๙

การตรวจร่างกายตามระบบ
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สรุปผลการตรวจทางห้องปฏิบตั ิการตั้งแต่แรกรับจนถึงปัจจุบนั

ชนิดการตรวจ ค่าปกติ ค่าที่ตรวจได้

ให้ระบุวันที่ตรวจ การแปลผล(สอดคล้องกับผู้ป่วยที่ศึกษา)
…/…./…… …/……/… …/…./……
CBC
Hb 12-18 mg%
Hct. 40-50%
RBC
MCV 80-98
MCHC 27-31
WBC 4.5K-10K
Neutrophils 40-75%
Lymphocytes 25-35%
Monocytes 2-10%
Basophils 0-1%
Eosinophils 0-6%
Platelets 140K-400K
Renal function tests
BUN 9-23
Cr. 0.45-1.1
eGFR >/=90
Electrolytes
Na. 132-146
mmol/L
K 3.5-5.5
mmol/L

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๐
ชนิดการตรวจ ค่าปกติ ค่าที่ตรวจได้
ให้ระบุวันที่ตรวจ การแปลผล(สอดคล้องกับผู้ป่วยที่ศึกษา)
…/…./…… …/……/… …/…./……
Cl. 99-109
mmol/L
Total CO2 20-31
mmol/L
LFT
Total bilirubin 0.3-1.2
mg/dl
Direct bilirubin 0.1-0.3
mg/dl
Indirect 0.1-0.8
bilirubin mg/dl
Alkaline 446-116
phosphatase mg/dl
SGOT(AST) 1-33 U/L
SGPT(ALT) 10-49 U/L
Albumin 3.2-4.8
Globulin 2.3-3.4
Coagulation test
PT 10-14 sec.
APTT 23-33 sec.
INR 0.8-1.1
ABG
pH 7.35-7.45
pCO2 35-45
-
HCO 3 22-26
pO2 80-100
ผลการตรวจทางห้องปฏิบัติการ
อื่น ๆ

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๑
ชนิดการตรวจ ค่าปกติ ค่าที่ตรวจได้
ให้ระบุวันที่ตรวจ การแปลผล(สอดคล้องกับผู้ป่วยที่ศึกษา)
…/…./…… …/……/… …/…./……

สรุปปัญหาจากผลการตรวจทางห้องปฏิบัตกิ าร
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อ้างอิง ...................................................................................................................................................................................

การตรวจพิเศษ/ผลการตรวจ (วันที่ ..................................) พร้อมแปลผล

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คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๒

ยาที่ผู้ป่วยได้รับ
ยา สารน้าทางหลอดเลือดดา และ ระบุกลุ่มยา กลไกการออกฤทธิ์ ผลข้างเคียง เหตุผลในการใช้ยา
อาหารทางหลอดเลือดดา คุณสมบัติ ในผู้ป่วยรายนี้
(ขนาด ทางที่ให้ เวลา) และวันที่ที่
ได้รบั
1.

2.

3.

4.

5.

6.

7.

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๔

สรุปพยาธิสภาพในผู้ป่วยรายนี้ (สาเหตุ อาการและอาการแสดง กลไกการเกิดโรค ปัญหา การรักษาและพยาบาลใน

รูปแบบ concept mapping)
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อ้างอิง.................................................................................................................................................................

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๕

สรุปอาการและอาการแสดง ตัง้ แต่แรกรับจนถึงปัจจุบัน

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V/S (ช่วงที่ไปศึกษาcase) :
BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๖

สรุปปัญหา อาการและอาการแสดง ในช่วงวันที่ศึกษา (แยกเป็นรายวัน)

วันที่ 1 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg

วันที่ 2 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg.

วันที่ 3 วันที่........................................
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V/S : BT =………..…. C, PR=…………….……. Bpm, RR=……………………….bpm, BP=…………………………..mmHg

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๗

การวางแผนการพยาบาล (วันที่.................................................)
ข้อวินิจฉัยการพยาบาล กลไกการเกิดปัญหา วัตถุประสงค์และ กิจกรรมการพยาบาล เหตุผลกิจกรรมการ ประเมินผลการพยาบาล
และข้อมูลสนับสนุน เกณฑ์การประเมิน พยาบาล

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๘
ข้อวินิจฉัยการพยาบาล กลไกการเกิดปัญหา วัตถุประสงค์และ กิจกรรมการพยาบาล เหตุผลกิจกรรมการ ประเมินผลการพยาบาล
และข้อมูลสนับสนุน เกณฑ์การประเมิน พยาบาล

อ้างอิง ......................................................................................................................................................................................................................................................
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คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๔๗

การวางแผนการพยาบาลในช่วงวันที่ศึกษา (เรียงลาดับตามวันที่ที่ดูแล)
วันที่.........................................
ข้อวินิจฉัยการพยาบาล กลไกการเกิดปัญหา วัตถุประสงค์และ กิจกรรมการพยาบาล เหตุผลกิจกรรมการ ประเมินผลการพยาบาล
และข้อมูลสนับสนุน เกณฑ์การประเมิน พยาบาล

คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6

 ๓๗

สรุปผลการดูแลและการเปลี่ยนแปลงของผู้ป่วย
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การวินิจฉัยครั้งสุดท้าย (ก่อนจาหน่าย)
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คาแนะนาที่จาเป็นหรือแผนการจาหน่ายสาหรับผู้ป่วยรายนี้
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................................................................................................................................................................. อ้างอิง
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คู่มือการศึกษาภาคปฏิบตั ิวิชา ปฏิบัติการพยาบาลผู้ใหญ่และผูส้ ูงอายุ ๑ ปีการศึกษา ๒๕๖6