NSG125 Transition to Professional Nursing course NSG125 Full Care Plan Revised
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED
Instructions:
During the NSG125 Transition to Professional Nursing course, students will complete a total of one care plan assignment as follows:
1. Care Plan based on a simulated client case from Shadow Health – OR
2. Care Plan based on a clinical site client.
Care Plan Map Components:
· Part I: Physical Assessment
· Part II: History & Physical
· Part III: Medications
· Part IV: Diagnostic Studies & Interpretation/Assessment Explanation
· Part V: Clinical Judgement Measurement Model Table
Rubric: Must achieve 16 points to pass clinical.
1. Care Plan based on a simulated client case- OR a Care Plan based on a clinical site client
Criteria |
4 points |
3 points |
2 points |
0 points |
Total Points |
Part I: Physical Assessment |
All components of the physical assessment are present. |
Most of the information is provided with all areas addressed. No more than 3 missing areas. |
No more than 6 of the assessment areas are lacking information. |
Assessment information not provided |
|
Part II: History & Physical |
Information is complete and accurate; All areas of the section are addressed. |
Most of the information is provided with all areas addressed. No more than 3 missing areas. |
No more than 6 of the history & physical areas are lacking information. |
Assessment information not provided |
|
Part III: Medications |
Information is complete and accurate; All areas of the section are addressed. |
Most of the information is provided with all areas addressed. No more than 3 missing areas. |
No more than 6 of the history & physical areas are lacking information. |
Assessment information not provided |
|
Part IV: Diagnostic Studies & Interpretation/Assessment Explanation |
Information is complete and accurate; All areas of the section are addressed. |
Most of the information is provided with all areas addressed. No more than 3 missing areas. |
No more than 6 of the history & physical areas are lacking information. |
Assessment information not provided |
|
Part V: Clinical Judgement Measurement Model Table |
Information is complete and accurate; All areas of the section are addressed. |
Most of the information is provided with all areas addressed. No more than 3 missing areas. |
No more than 6 of the history & physical areas are lacking information. |
Assessment information not provided |
|
Total points |
/20 |
Part I: Physical Assessment
VS Time: Temperature Pulse Respirations BP / Pain /10
VS Time: Temperature Pulse Respirations BP / Pain /10
GENERAL SURVEY |
|
Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic Height___________ Weight____________ Well-groomed Poorly Groomed Facial Expression: Content Happy Anxious Sad Angry Flat |
|
NEUROLOGICAL |
|
(LOC) Level of Consciousness |
Alert Awake Lethargic Obtunded Stupor Comatose Confused Oriented x 4: If not alert X 4, circle what they are alert to: Person Place Time Situation |
Eyes |
Unaided sight Glasses Contact lens Blind |
Pupils |
Equal Round Reactive to light Accommodates List abnormal findings:________________________________________ Pupil reaction: Brisk Sluggish Nonreactive to light Pupil size: before light ______mm after light ______mm |
Ears |
Unaided hearing Hard of hearing Deaf Hearing aid Implant |
Extremity Strength |
Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal |
Pain |
Location: Onset (when did it start): Provokes (makes it worse): Palliates (makes it better): Quality (description): Radiate: location: Severity: ___/10 Time: Constant Intermittent |
CARDIOVASCULAR |
|
Skin / Mucous Membranes |
Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic |
Radial and Pedal Pulses |
Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent |
Apical Radial Pulses |
(2 assessed simultaneously) Equal Pulse Deficit |
Capillary Refill |
Normal (<3 Sec) ______sec Location:________________ |
Edema |
Absent Present: location +1 +2 +3 +4 Non-Pitting |
Heart Rhythm/ Sounds – S1S2 |
Heart Rhythm: Regular Irregular Heart Sounds: S1/S2 Murmur Extra Sounds Sound: Strong Distant |
IV |
None Solution_______________ Rate ____ml/hr Site location (be specific) ______________________________________ Site appearance: WNL Edema Erythema Tender Pallor Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________ |
RESPIRATORY |
|
Respirations |
Pattern: Regular Irregular Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction Chest Expansion: Symmetrical Asymmetrical |
Lung Sounds |
Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______ Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______ |
Cough |
None Non-productive Productive Sputum: amount color |
Oxygen |
Room air O2 at_____L/min Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask |
Respiratory Treatments |
Incentive Spirometer (IS): ml______ # of times______ Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________ |
GASTROINTESTINAL |
|
Oral |
Mouth: Teeth Dentures Caries Swallowing: Gag reflex Dysphagia Mucous Membranes: intact moist dry pale pink |
Abdomen: |
Contour: Soft Round Flat Scaphoid Obese Palpation: Firm Hard Tender Non-Tender Location: Distention: Nondistended Distended |
Bowel Sounds |
RLQ Normoactive Hypoactive Hyperactive Absent RUQ Normoactive Hypoactive Hyperactive Absent LUQ Normoactive Hypoactive Hyperactive Absent LLQ Normoactive Hypoactive Hyperactive Absent |
NG/ GT/ JT |
None Type of tube _____ patent non-patent Purpose: Suction Feeding Medication Administration Type of food: _________ Fluid Flush__________mL |
Bowel Movement |
Continent Incontinent Last BM__________ Color Consistency Ostomy: yes no |
Nutrition |
Self-feed Needs assistance Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________ Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed Tube Feed: Yes or No |
GENITOURINARY |
|
Urine |
Continent Incontinent Urgency Hesitancy Frequency Burning Nocturia Catheter type _______________ None Color_________________ Clear Cloudy Sediment Burning Frequency |
Intake and Output |
PO/Oral/Tube Feed intake____________ mL IV intake____________ mL Urine output_________ mL Other output_________ mL Fluid restriction ___________mL/day |
MUSCULOSKELETAL |
|
ROM |
Active ROM: Completed____________ Passive ROM: Completed____________ |
Mobility |
Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair Walks: distance frequency tolerance PT OT |
Other Musculoskeletal |
Cast: Location: Brace: Type: Location: Amputation: Location: |
Risk for Falls |
Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board |
INTEGUMENTARY |
|
Appearance |
Color: Normal for Ethnicity Pallor Rash Bruise Lesions Intact OR Non-Intact: Location of Non-Intact Areas_____________________________________________________ New Scars: Location _________________________ Dressing change: (describe: location, steps, drainage, wound) |
Temperature and Moisture |
Temperature: Warm Hot Cool Cold Moisture: Dry Moist |
Incisions/Wound |
None Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________ Wounds Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough Collepals.com Plagiarism Free Papers Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS Why Hire Collepals.com writers to do your paper? Quality- We are experienced and have access to ample research materials. We write plagiarism Free Content Confidential- We never share or sell your personal information to third parties. Support-Chat with us today! We are always waiting to answer all your questions. All Rights Reserved Terms and Conditions |