This assignment will be completed in a group. Each group will be assigned a diagnosis by the instructor of the course. The students will work in a group to create a patient case using the Care Plan C

Nursing Care Plan Part I: Demographics, History

Date:

A. Client identifiers:

Physician (s):

Age: Gender: Ht: Wt. Code Status:

Isolation Status:

Chief Complaint (OPQRST detail)

Health States

Date of admission:

Activity level: Diet:

Fall risk

Client’s description of health status (define chronic state)

Client’s past medical and surgical history (include dates)

Allergies: (include type of reaction)

Surgical history

Family medical/Surgical History:

Interdisciplinary Consults (PT/OT/ST/RT/other)

Referrals to Specialists (pulmonary, cardiac, neuro etc.)

Socio-cultural Orientation

Cultural and Ethnic Background

Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, financial abuse)

Family system Elements (Support system)

Spiritual:

Occupation (across the lifespan)

Functional Assessment:

Barriers to independent living

Part II: Medications

List all medications, dosages, classifications, and rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication.

** Must include evidence to support the use of all relevant medications listed in the client's chart: citations are required, reference listing at the end of the packet.

ALLERGIES:

Medication, Classification, Mechanism of Action

Dosage/Route

Contraindications, Adverse Reactions/Side Effects, Risk Factors,

Client Education and Nursing Implications

Why is this client getting this medication?

Medication, Classification, Mechanism of Action

Dosage/Route

Contraindications, Adverse Reactions/Side Effect, Risk Factors,

Client Education and Nursing Implications.

Why is this client getting this medication?

Lab

Normal Range

Baseline Results

Hematology

WBC diff

Coagulation studies

Arterial Blood Gases

Chemistry

Urinalysis

Other

Part IV: Relevant Diagnostic Studies and Interpretation

Diagnostic Test

Date and time of Study

Findings

Date and time of repeat study if applicable

Findings

CARE PLAN PART V: PHYSICAL EXAM (complete the admission physical exam)

Vital Signs/Pain/Pulse Ox:

Temp: _______ Location: O, A, R, T

Apical Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic  Thready  Bounding  Strong

Respirations: Rate = ____; Rhythm:  Even  Regular  Irregular  Labored  Strained  Moderate

 Shallow  Deep  With stridor / retractions / apnea noted

Blood Pressure: _____/_____; Arm: R / L; Client’s Position: Lying / Standing / Reclining / ___________

Pain: Scale (1 - 10) ___; Nonverbal cues: ________________; Loc: ______________; Onset: ________________;

Duration: ____________; Quality: ____________________

Client states,

Neuro:

LOC: Alert & Oriented X:  1,  2,  3; Oriented to:  Person,  Place,  Time;

Disoriented to:  Person,  Place,  Time

Affect/Mood:  Alert,  Flat Affect,  Tearful,  Confused,  Pleasant,  ________________

Glascow Coma Scale: Total Score= ____; Eyes, open  4=Spontaneously,  3=to speech,  2=to pain,  1=n/a

Verbal Response:  5=oriented,  4=confused,  3=inappropriate words,  2=incomprehensible sounds,  1=n/a

Motor Response:  6= obeys commands,  5=localized pain,  4=flexion w/drawl,  3=abnormal flexion,

 2=abnormal extension,  1=flaccid

Pupil Size & Reaction:  PERRLA,  unequal,  misshapen,  unreactive to light,  no accommodation

Vision: Left = ____/____ Right = ____/_____,  Nearsighted,  Farsighted,  Astigmatism (L or R)

Corrective lenses:  Glasses,  Contacts, Abnormal findings: _____________________________

Hearing:  Normal,  Loss (L or R)  Degree: ____________,  Hearing aid,  Pain,  Ringing  Rushing

Communication:  Lucid  Coherent  Incoherent  Slurred speech  ________________

Facial Symmetry:  Symmetrical  Unsymmetrical (location) ______________

Client states,

Cardiac:

Heart sounds:  clearly audible,  muffled at A, P, E, T, M

Sounds are:  with  free of  murmurs and / or  gallops

PMI: Location of palpation = ___________________

 Apical Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Brachial Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Temporal Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Carotid Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

• Femoral Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Popliteal Pulse: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Posterior Tibial: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

 Dorsalis Pedis: Rate = ____ BPM; Rhythm:  Regular  Irregular/erratic;

Strength:  Thready (+1)  Weak (+2)  Normal (+3)  Bounding (+4)

Capillary Refill: fingernail / toenail,  Brisk,  Rapid,  Sluggish (1, 2, 3, __ seconds)

Client states,

Respiratory

Respirations are:  Even,  Regular,  Irregular,  Labored,  Strained,  Deep,  Shallow

With:  Stridor,  Reactions,  Apnea noted

Chest expansion is  symmetrical  not symmetrical (more rise on  left,  right)

Breath sounds are:  Clear anteriorly & posteriorly,  Clear bi-laterally,  Free of adventitious sounds,

 w/ wheezes noted in __________________, w/ crackles noted in __________________________

Client experiences:  shortness of breath,  difficulty with respirations

Cough is:  productive,  nonproductive; Sputum description: _______________________________________

GI/ Abdomen

Abdomen is:  Soft,  Round,  Hard,  Protuberant,  Flat,  Firm,  Tender to palpation,  Nontender,

 Distended,  Nondistended

Bowel sounds are:  Audible X 4,  Inaudible in ___Q,  Active X 4,  Inactive in ___Q,  Hyperactive,

 Hypoactive,  Faint

Abdominal skin exhibits:  Edema,  bruises,  Lesions,  Rashes,  Ulcers,  Scarring,  Stretch marks

 coloration ________, Location of findings: _______________________________________________________

Normal elimination patterns: Bowels = ________, Urinary = ________

Last BM = ________________, Last Urination = _________________

 Has catheter. Note color, odor, consistency, and amount of urine: _____________________________________ ____________________________________________________________________________________________

Stool is:  Color: ____________,  Watery,  Soft,  Diarrhea,  Uniform,  Hard,  Tarry,  Loose

Urine is:  Straw colored,  clear, cloudy,  w/ sediment noted,  yellow,  amber,  bloody,

 tea-colored,  malodorous

Client:  is continent,  incontinent,  wears adult briefs

Musculo-skeletal: Extremities

Muscle strength in legs & feet (foot push):  Strong,  Weak,  Equal,  Exhibits Homan’s sign

Hand Grasps:  Firm,  Weak,  Equal,  Unequal (stronger in ___ hand).

ROM:  Limited,  Partial,  Full,  Active,  Passive

ADLs: Requires assistance for:  Feeding,  Bathing,  Dressing,  Toileting,  Transferring,  Continence

Gait/balance: movements are  uncoordinated  coordinated ( arms swing freely,  head & face lead body)

 Client has history of falls. How often = _________________, Last fall = ___________________

Client ambulates  with,  without assistance.

 Client moves with use of assistance devices ( Cane,  Walker,  Crutches,  Wheelchair,  ____________)

Client exhibits in extremities:  lack of sensation,  Edema,  Missing Limbs

Note location of findings: ________________________________________________________

Integumentary

Skin color =  pink,  jaundiced,  ashen,  pallor,  pale,  reddened/erythema,  cyanotic,  ___________

Skin temp =  warm,  cool,  cold,  hot,  clammy

Skin Turgor: after pinching, skin on sternum returns to normal in ____ sec.

Skin is  dry,  moist,  with lesions,  w/o lesions,  with breaks,  with rash

Note location of findings: _________________________________________________________

Client has  incisions,  wounds  dressings (location: ­­­­­­­­­­­______________________________________________)

Mucous membranes are:  moist,  pale,  pink,  pallor

Condition of teeth & gums:  missing teeth,  edentulous,  wears dentures (note fit: ______________________)

 dental caries,  bleeding gums,  dry mouth,  moist mouth,  _______________

Other:

Height = ______ in.; Weight = ________lbs.; BMI (weight/height2 X 704) = ________ (optimal BMI = 19-25)

Recognize Cues

Identify abnormal clinical manifestations, labs, or diagnostics. Consider risk factors and medical history.

Analyze Cues

List the problems and the clinical manifestations that support the problem/diagnosis.

Prioritize Hypotheses

Using the Analyze Cues column, indicate the priority diagnosis or problem. Provide rationale for prioritization and include a citation for the resource..

Generate Solutions

List 15-20 interventions needed for this client. List contraindications if any, exist for this client.

Take Action

Prioritize the top three (3) interventions based on client needs.

Evaluate Outcomes

Categorize the findings which indicate an improvement or a decline in the client’s health status.