Nursing Care Plan
Rev 08/20
Student Name:
Date:
1
Hillsborough Community College Department of Nursing – Client Data Tool / Care Plan
Student: Instructor: Date:
2
Pt Initials: Age: M / F Adm Date: Checklist
Admitted From: Home LTC ALF/NH ID Bracelet On DNR Advanced Directives
Other: Allergy Bracelet On Fall Risk Precautions
Admission Diagnosis: Seizure Precautions BA52 Suicide Precautions
Assault Precautions
Vital Signs
Chief Complaint on Admission / Hx of Present Illness:
0800
1200
1600
NKA - No known allergies
Medication Allergies (list & type of reaction) :
Isolation / Type: _ _
Accucheck / Results
HL IV CVL PICC Other:
IV Fluids / Drips
Food or Other Allergies (list & type of reaction): NPO NPO for Procedure
Dietary Intake Bkft________% Lunch _ %
Oral Intake: _ ml Voided _ml Foley_______ml
Intake in 24 hours:________ml Output in 24 hours:_ ml
Past Medical History
No previous history / major illness Oral Care Bath Self / Partial / Complete
Neurologic Incontinent Care Feeding Assist / Complete
Incentive Spirometer Deep Breathing Exercises
Respiratory Suction Tracheostomy Care Trach Suctioning
_ Tube Placement / Residual Check Bladder Scan
Catheter Care Ostomy Care Ambulation / Activity
Cardiovascular Wound Care Foley Care ROM
_ _
Musculoskeletal _ _
Equipment
Gastrointestinal Telemetry External Pacemaker Apnea Monitor
Wall Suction Incentive Spirometer Oxygen
Genitourinary Pulse Oximeter Yankauer Suction Chest Tube
IV Pump PCA Pump Epidural Pump CPAP
Integument Feeding Pump Heating Pad Cooling Blanket
Special Bed / Type________________Breast Pump
Endocrine Restraints Sling Walker Cane
SCD AE hose Traction Cast
Psychiatric
Family Assessment:
Past Surgical History Primary Caregiver:
No previous surgical history Family Members:
Parental Interaction (peds):
Culture / Ethnicity:
Impact on Care:
Procedures / Surgeries This Hospitalization
_
_ Erickson’s Developmental Level
_
Illness / Hospitalization Effect on Ability to Achieve Tasks:
3
Neurological / Cognitive / Perceptual / Psychosocial
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Level of Consciousness: Altered High Risk for Injury
Awake, alert and oriented to Disoriented to: Altered Level of Consciousness
person, place and time Person Place Time Altered Thought Process
Follows commands Drowsy Lethargic Forgetful Confused Knowledge Deficit
Clear speech Speech: Slurred Aphasic Memory Deficit
Bilateral hand grasps equal Absence of support system Anxious Sensory Deficit
Able to verbalize understanding of
Hostile Flat affect Tearful Depressed Anxiety
current health state
Angry Uncooperative Difficulty sleeping Body Image Disturbance
Maintains eye contact
Lack of interaction Hopelessness
Behavior is appropriate for age
and development Abnormal involuntary movement tremors Powerlessness
Communicate thought processes Clonus Situational Low Self-Esteem
Primary language: English Altered Sensory Perception
Spanish Other Describe behavior:
_ Consultation
Social Services
Subjective data: Psychiatry Neurology
Respiratory
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Breathing: Dyspneic Tachypneic Non- Productive Activity Intolerance
Lungs clear bilaterally Secretions: Thin Clear Frothy Thick Fatigue
Respirations even, regular, White Yellow Tan Green Blood–tinged Impaired Gas Exchange
and non-labored Oxygen: O2: via or Room Air Impaired Physical Mobility
No productive cough, Oxygen Saturation: % Ineffective Airway Clearance
prolonged fever or night sweats Subjective data: Ineffective Breathing Pattern
O2 Sat > 95% Self-Care Deficit
SMOKER: History Present Deficient Knowledge
Pack Years Ineffective Health Maintenance
Cessation Attempts Y / N
Lobes RUL RML RLL LUL LLL
Consultation
Crackles Respiratory Care
Pulmonary Rehab
Rhonchi
Wheezes
Cardiovascular
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Arrhythmia: Afib Other Altered Tissue Perfusion
S1 S2 Rhythm Interpretation: Murmur S3 S4 Decreased Cardiac Output
Rhythm regular Skin: Cool Cold Pale Cyanotic Warm Acute Pain
No edema Reddened Pulses: Radial Right Radial Fluid Volume Deficit
Left Pedal Right Pedal Left Fluid Volume Excess
Peripheral pulses 2+
Other: Pulse Scale: D = Doppler 0=Absent Impaired Cardiac Output
palpable 1+ = Weak/Thready 3+ = Bounding Capillary refill: > 3 Activity Intolerance
Capillary refill< 3 sec seconds Edema: Deficient Knowledge
No chest pain Location(s)/Severity Ineffective Health Maintenance
No dyspnea Anxiety
Normal sinus rhythm (NSR) Pediatric: Heart rate irregular
Subjective data: Consultation
Physical Therapy
Intake in 24 hrs. Output in 24 hrs. Occupational Therapy
4
Musculoskeletal / Activity / Exercise
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Weakness: RUE LUE RLE LLE High Risk for Injury
Ambulatory Limited ROM Location: Noncompliance
No assistive devices or Paralysis Amputation Altered Protection
limitations Mobility Status: Ambulatory w/assist Activity Intolerance
Independent with ADLs Nonambulatory / Chair or Bed Bound Impaired Physical Mobility
Usual ROM to all extremities Gait: Unsteady gait Ataxic Fall Risk: High Fatigue
Symmetry of strength Moderate Fall Risk /Safety Measures Initiated Impaired Bed Mobility
Present
Repositions self
Assistive Devices: Cane Walker Belt
Steady gait Consultation
Crutches Other:
Fall Risk Assessment Tool Physical Therapy
Score Occupational Therapy
Traction Type:
Restraints Type:
Cast(s)
Subjective data:
Gastrointestinal / Nutrition
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Gastro: Difficulty chewing Difficulty swallowing Altered Nutrition:
No diet restrictions Vomiting: with / without nausea Nausea Loss of Less Than Body Requirements
Feeds self More Than Body Requirements
No difficulty chewing/ appetite
swallowing Fluid Volume Deficit
Abdomen soft and non-
distended Frequency / Episodes: Fluid Volume Excess
Bowel sounds present and Character of emesis: Impaired Skin Integrity
normoactive Bowel: Incontinent Diarrhea Frequency / Episodes: Impaired Swallowing
No nausea, vomiting or Potential for Aspiration
diarrhea
BM pattern satisfactory for Character of stool: Constipation
patient Constipated Last BM Diarrhea
Good appetite / adequate Character of stool: Knowledge deficit
nutritional intake
No unintentional weight Tarry Stools Bloody
Abdomen: Hard Tender Distended
loss/gain
Cultural or religious food Bowel Sounds: Absent Hypoactive Hyperactive
requests
No identified food Consultation
intolerances Dietician / Nutritional Support
Speech Therapy
Height Weight
Admit Wt. Speech Pathology Evaluation
Current Wt. (swallow study)
BMI
Stoma: Location:
Dusky Black Pink / Red
Nutrition: Special diet:
PEG Gastrostomy Tube Jejunostomy Tube
Parenteral Nutrition - Type:
Thickened liquids
Tube feeding – cont. bolus Type:
Supplement(s) - Type:
Tubes/Drainage:
Intake in 24 hrs. Output in 24 hrs.
Subjective data:
5
Urinary
Normal Parameters Variances / Deviations Care Concerns
Within Defined Parameters: Nocturia Dysuria / burning Frequency Incontinence
Continent Urgency Incontinence Hematuria Dribbling Stress Incontinence
Urine clear or yellow-amber Bladder distention Bladder spasms Urinary Retention
No c/o nocturia, dysuria, Stress incontinence Infection/actual
Urine Color: Urine Character: Cloudy Altered comfort
frequency, urgency or
Concentrated Sediment Malodorous
hematuria Altered Elimination Pattern
Intake in 24 hrs Output in 24
Adequate output hrs. Tubes/Drains: Type: Fluid Volume Excess
Location: Drainage:
Catheter: Type # Fr.
Date placed:
Stoma: Location:
Dusky Black Pink / Red
Dialysis: access
Anuria Oliguric
Post TURP CBI
Subjective data:
Integument
Normal Parameters Variances / Deviations Care Concerns
Skin intact, Color Condition Turgor Temperature Impaired Skin Integrity
warm, and dry High Risk for Infection
Color WNL Infection Actual
Pale Mottled Dry Rash Poor Cool Cold
Turgor elastic Cyanotic Lesions Tenting Hot _
Mucous Jaundiced Ecchymosis
membranes pink, Flushed
moist and free of
lesions Wounds: Type: _
No rashes Location: _
Braden Score Appearance:
Dressing Changed: Y / N Drain present: Y / N Type:
Drainage(Color / Character / Amount):
IV Site: _
Subjective data:
Pain Assessment
Normal Parameters Variances / Deviations Care Concerns
No pain reported Client’s description of: _ Acute Pain
Location: Chronic Pain
Intensity (score 0-10): Ineffective Coping
Pain Scale: Wong Faces FLACC Numeric (0-10) Quality Deficient Knowledge
of Pain: Sharp Dull Aching Constant Intermittent
Pressure Tightness Squeezing Heavy Associated
Symptoms:
Aggravating factors:
Relieving factors:
_
Subjective data:
6
Describe any patient education you provided your client during your shift. Consider health promotion, discharge
planning (home care), safety, nutrition etc.
Laboratory and Diagnostic
Testing
Lab Results:
CBC WBC RBC Hct Hgb Plt
BMP Na+ K+ Cl- BUN Creatinine Glucose
Coag PT PTT INR BNP Troponin
Lipid Panel
Rationale for abnormal labs
Cultures blood urine respiratory wound
Other significant lab results:
Diagnostic Tests (dates, results, rationales for findings)
x-ray
CT scan
MRI
Ultrasound
Echocardiogram
Cardiac Catherization
Colonoscopy
Other
7
8
Priority Patient Problem 1
Objective Assessment Cues: Subjective Assessment Cues:
Patient Problem
Goal: (Specific Measurable Attainable Realistic Timely)
9
Interventions: Rationales:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Evaluation: (Goal met or unmet.) (Summarize patient progress toward goal.)
1
0
Priority Patient Problem 2
Objective Assessment Cues: Subjective Assessment Cues:
Patient Problem
Goal: (Specific Measurable Attainable Realistic Timely)
7
Interventions: Rationales:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Evaluation: (Goal met or unmet.) (Summarize patient progress toward goal.)
8
Priority Patient Problem 3
Objective Assessment Cues: Subjective Assessment Cues:
Patient Problem
Goal: (Specific Measurable Attainable Realistic Timely)
7
Interventions: Rationales:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Evaluation: (Goal met or unmet.) (Summarize patient progress toward goal.)
8
Medication List
Drug name Indication Nursing assessment Patient
Teaching
9
Medication List
Drug name Indication Nursing assessment Patient
teaching
9
References
