Nursing Clinical Packet Patient Assessment and Care Plan
Nursing Clinical Packet Patient Assessment and Care Plan
Nursing Clinical Packet Patient Assessment and Care Plan
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Nursing Clinical Packet Patient Assessment and Care Plan
Instructions to student:
1) Bring one copy of this packet with you to clinical each week.
2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet.
3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.
4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly. Nursing Clinical Packet Patient Assessment and Care Plan.
PATIENT ASSESSMENT FORM
| STUDENT NAME: | DATE: |
| CLIENT INITIALS: | ROOM # | DOB: | AGE | GENDER: | ADMISSION DATE: | ||||
| CODE STATUS: | ALLERGIES: | MARITAL STATUS: | OCCUPATION (FORMER): | ||||||
| MEDICAL DX: | CHIEF COMPLAINT: | ||||||||
| PAST HISTORY (SURGERY/PROCEDURES) WITH DATES | |||||||||
| ORDERS | RATIONALE (Why is this ordered for this client???) | ||||||||
| EXAMPLE: DIET | 2 g Sodium diet with nectar thick liquids only | Sodium is restricted due to edema in the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke. | |||||||
| DIET | |||||||||
| ACTIVITY | |||||||||
| I/O | |||||||||
| VS | |||||||||
| BGM | |||||||||
| FOLEY | |||||||||
| NG | |||||||||
| PEG/PEJ TUBE | |||||||||
| WOUND CARE | |||||||||
| RESPIRATORY TREATMENT | Nursing Clinical Packet Patient Assessment and Care Plan | ||||||||
| TRACHEOSTOMY | |||||||||
| SUCTIONING | |||||||||
| CHEST TUBE | |||||||||
| SPECIAL EQUIPMENT | |||||||||
| LAB ORDERS | |||||||||
| OTHER | |||||||||
| REHAB SERVICES | ACTIVITY OR TREATMENT PLAN & SCHEDULE | RATIONALE | |||||||
| PHYSICAL THERAPY | |||||||||
| SPEECH THERAPY | |||||||||
| OCCUPATIONAL THERAPY | |||||||||
/ 5 pts
IVs
| IV FLUID AND RATE: | SITE LOCATION AND CONDITION: |
| LAST DRESSING CHANGE: | LAST TUBING CHANGE: |
| GAUGE: | REASON FOR IV ACCESS: |
| DIAGNOSTIC TESTS: | DATE | RESULTS | REASON FOR TESTING AND IMPLICATIONS FOR NURSING CARE |
| LAB TEST | DATE | RESULTS | NORMS REFERENCE RANGES | IMPLICATIONS FOR NURSING CARE (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP IMPROVE AN ABNORMAL RESULT?) |
GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development)
| CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO HAVIGHUSRT | TASKS OF THIS STAGE:
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| ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF TASKS
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/ 5 pts
MEDICATIONS
If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below. Nursing Clinical Packet Patient Assessment and Care Plan.
| Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
| Coreg (carvedilol)
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3.125 mg – 50 mg BID | Asthma, heart block |
| Pharmacotherapeutic Class | Dosage, Route & Frequency | Adverse Reactions |
| β-adrenergic blocker
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6.25 mg p.o. BID | Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm |
| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
| He has a history of hypertension but has been taking Coreg for 2 years to control his hypertension
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BP’s for past 3 days have been 128/78, 132/72, 138/80
How is this medication impacting your client??B/P readings, lab results, pain management, etc…….. |
Do not discontinue abruptly or before surgery
Caution with Upper airway dysfunction Nursing Clinical Packet Patient Assessment and Care Plan Rise slowly to minimize orthostatic hypotension, check B/P and heart rate prior to administration Take before meals |
| #1 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route & Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #2 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| #3 Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #4 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #5 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| # 6 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #7 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #8 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #9 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #10 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #11 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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| #12 Brand Name and Generic Name | Normal Dosage Ranges | Contraindications |
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| Pharmacotherapeutic Class | Dosage, Route and Frequency | Adverse Reactions |
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| Why this Patient Receives this Med | Effects of the Med on the Client | Nursing Considerations and Teaching |
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/ 20 pts
NURSES NOTES FOR CLINICAL
For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments. We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long term care resident follows below.
| TEMP: | APICAL HR: | RESP: | BP: | HT: | WT: |
| DATE / TIME | (TYPE HERE)
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Sample Narrative Note — Head to Toe format
| Temp: 98.6 | Apical HR: 72 | Resp: 16 | BP 128/62 | Ht: 5’10” | Wt: 145 |
| 12/22/2010 1400 | Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without erythema or exudate. No chewing or swallowing difficulties. 75% of general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal. Motor and sensory functions grossly intact. No weakness or paralysis. Upper extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion. Apical pulse regular (rate) and rhythm. Double lumen picc line note to left antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this morning, passed a large, soft- formed brown stool and a moderate amount of clear yellow urine. Bilateral lower extremities, no tenderness, swelling or joint deformities noted. Denies numbness or tingling to extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses palpable and equal bilaterally. |
PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down your assessment findings.)
| ROUTINE FINDINGS | PATIENT VARIATIONS/ABNORMALS |
| COGNITION/NEUROLOGICAL (SAMPLE) Alert and oriented x3, recent and remote memory intact. Denies any numbness or tingling to extremities” | (SAMPLE) “Fine resting tremor of left hand
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| SKIN
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| SENSORY | Wound measurements and complete description if available at the very least Document dressing including the type of dressing and description of condition! |
| BREASTS – | DEFERRED. |
| RESPIRATORY – | (Include ventilator settings as indicated in narrative note)
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| CARDIOVASCULAR | Include any vascular access device, IV lines, AV fistulas, perma -cath lines, etc.
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| ABDOMEN –
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Include any enteral feedings here and route
BOWEL CONTINENCE? LAST BM? BOWEL PLAN? |
| MUSCULOSKELETAL – |
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| GENITOURINARY – | URINARY CONTINENCE? TOILETING PLAN?
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| PELVIC – | DEFERRED.
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| RECTAL – | DEFERRED. |
/ 10 pts
NURSING CARE PLAN
Begin your NCP by listing ALL your clients individual problems (at least 10) and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority Nursing Clinical Packet Patient Assessment and Care Plan. Risks would not be priority 1, 2, or 3!!!!!
Expectation is to have at least 10 nursing diagnosis listed!
| # | List the Client problem | An appropriate Nursing Diagnosis stem
(REFER TO YOUR NURSING DIAGNOSIS LIST) |
Related to part of the statement (This is individual to your client) | As evidenced by part of the statement (This is individual to your client)
REMEMEBR THIS IS NOT USED IN A “Risk For” diagnosis |
| 1 | SAMPLE: Reports severe pain in the right hip. | “Acute Pain” | “related to” fractured right hip | “as evidenced by” verbal report of pain rated at an 8 on a scale of 0 –to 10. |
| 2 | SAMPLE: Complete bed rest | “Risk for Impaired skin integrity” | “related to “ immobility | NONE it is a “Risk for” diagnosis so there is no evidence statement |
From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map. Nursing Clinical Packet Patient Assessment and Care Plan.
SAMPLE NCP
| NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal report of pain rated 8 on a scale of 0 -10. |
| ASSESSMENT
(Data that directly pertains to the above nursing diagnosis) |
OUTCOME STATEMENT
(Patient centered, realistic, specific, measurable, target time) |
INTERVENTIONS
(Individualized, specific, frequency) Minimum of 4-5 interventions per plan |
SCIENTIFIC RATIONALE
(Supporting statement from text or other source, cite source)
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EVALUATION OF OUTCOME
(Met, partially met, unmet, unknown by target time) |
| SUBJECTIVE DATA: “My right hip hurts me so much every time I move. I am so afraid to start physical therapy” | SHORT TERM: Client will report pain level rated at a 3 or lower 30 minutes after pain medication taken | 1. Educate the client on the importance of pain relief to enhance her rehabilitation efforts and include education on various types of methods to relieve pain.
2. Encourage client to express any questions or concerns she may have regarding pain management methods to alleviate anxiety and fears.
3. Educate the client on her responsibility to honestly report pain when it occurs as well as reporting if the current pain management is effective or ineffective for providing her pain relief
4. Provide for alternative/complementary measures of pain relief, such as, reduce lighting and noise, soothing music, pet therapy, massage, and hot/cold packs according to client preferences. |
1. “There are many ways to manage pain. In addition to pharmacologic and non-pharmacologic measures, simple
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