transfer original care plan to a new one the blank one and please do a apa style as instructed.

NUR 3005 Concepts Care plan INSTRUCTIONS TO STUDENTS: Submit ALL pages of the care plan in one document electronically via Canvas assignment upload. PART 1. CLINICAL INFORMATION Student name: _____________________ Clinical Day: ______ Age range (20-25, 26-30 etc.): Gender: M/F # of days since admission: Code Status: Reason for Admission (Diagnosis) & chief complaint: Clinical Date: ___________ S – Signs/symptoms (on admission)A – Allergies & reactionsM – Medications at homeP – Past medical/surgical historyL – Last placement before admission (home, other facility, nursing home, clinic, etc?)E – Events that led to the current problemExplain the pathology of your patient’s condition/surgery. List symptoms, risk factors. Cite your reference in APA format (no Google or .com): Baseline vital signs (AM vital signs)TempBP- HR- RR- O2 sat- 1. How often are you supposed to take vital signs? 2. Explain activity level, including what the patient can and cannot do. If the patient is on bed rest, justify why the order was written. 3. What type of diet is your patient on, or are they NPO? 4. Does the patient require any assistive devices? 5. Are there any special precautions for your patient? 1 Lab Tests Normal Ranges WBC 4,200 – 10,300/uL HGB 11.2 – 15.7 g/dL HCT 34.1 – 45% Platelets 160 – 383 k/uL Na 135 – 145 mmol/L K 3.6 – 5.0 mmol/L Cl 98 – 109 mmol/L CO2 22 – 31 mmol/L Mg 1.6 – 2.6 mg/dL BUN 6 – 23 mg/dL Creatinine 0.51 – 0.95 mg/dL Anion gap 6 – 16 mmol/L Glucose 70 – 139 mg/dL Results for previous date and day of clinical MM/DD MM/DD Relate abnormal value to disease process (potential cause of abnormal lab & pertinent sign/symptoms) PT 10.2 – 13.0 sec INR 0.9 – 1.3 PTT 25.1 – 36.5 sec Ca 8.4 – 10.2 mg/dL AST 10 – 35 U/L ALT 10 – 35 U/L Phosphorus 2.4 – 4.5 mg/dL Lactic acid 0.5 – 2.2 mmol/L BNP < 100 pg/mL Diagnostics (X-rays, CT scans, MRI, Echo, US, etc)- Include pertinent tests based on the client’s admitting problem. (Summarize results of the tests) 2 MEDICATION LIST Scheduled and/or PRN medications (denote CORE if on drug list) Drug Name Dose and Time Reason for taking drug Class/ Action Acetaminophen (example) 325 mg. po q4hours PRN Hip Pain CORE Assessment Data & Labs to monitor CORE Major side effects Important teaching CORE CORE 3 Intake & Output for your shift: Meals: Fluid intake Total PO Total Tube Feed: Total IV fluid: Total void: Voided: 0x 1x 2x 3x 4x 5x Total BM: 1x x2 x3 x4 Pain 0/10 -Location and description _____________ __________________ Intervention: ______________________________ _______________________________ _______________________________ Evaluation of your intervention: _______________________________ _______________________________ Weight on admission: Weight today: Total I&O per shift: Reassessment vital signs. Time: 1230 Intake: Temp- BP- Output: HR- RR- O2 satGENERAL ASSESSMENT Environmental checks Is the bed low? Is the brake on? Is the alarm on? Is the patient on restraint? Is the call light within reach? Does the patient have an IV? Where? What type of IV access? Is there a continuous IV running? What solution? How fast is it running? Does the patient have an NGT? Is there a running tube feed? What solution? How fast is it running? Does the patient have a Foley catheter? Is it secured and below the patient? Is it flowing? How much is in the bag? Does the patient have O2 therapy? How is it delivered? What is the amount of O2? 4 What else does the patient have that you can easily see? Three-point check: ABC – “Hands off” observations only Is the patient awake and communicating? How is the breathing- SOB, the effort of breathing? What is the color (general appearance)? PHYSICAL ASSESSMENT Narrate assessment data which will evolve into nurse’s notes: Objective Data: (Example) abd distended, absent bowel sounds Psychological: Pleasant, cooperative, hostile, withdrawn? Neurological: LOC, confusion, signs of dysphagia, lethargic, nonresponsive, follows commands, speech clear? Pupil size/accommodation (focused neuro assessment) CV: cap refill, heart rate regular/irregular, heart sounds, radial & pedal pulses 2+ (bil), edema (location), TED hose, SCD’s on? Pulmonary: Effort; any dyspnea or SOB? Anterior and/or posterior breath sounds— clear/course/rales/wheezes? Cough non-productive or productive w/ sputum characteristics? GI: Bowel sounds heard? Abd flat, protuberant, obese? Abd soft or firm/tender to palpation w/guarding? Where? Last BM & consistency (e.g., soft, hard, loose, diarrhea)? Nausea / Vomiting? Any appetite issues? 5 GU: Voids/Foley/incontinent. Urine characteristics? Dialysis access? Renal access thrill palpable? Integumentary: Abnormal skin color/Turgor, warm/cool, dry/damp, intact? Heels & coccyx blanchable? Pressure ulcer(s) (describe stage) & Surgical or other wounds: describe location, appearance, if dressing dry or drainage characteristics. Surgical drains? Musculoskeletal: Moves all extremities to command or FROM; any limited movement? Where? Strength in 4 extremities 5/5? Hand grips strong & equal? Gait stable/unstable? Independent in ADL’s; needs assist? Mobility device in use (walker/cane, etc.)? IV Site: IV gauge. Site location and appearance? Rate and type of IV fluid infusing or saline lock? 6 Points🡺 Braden Scale 1 2 3 4 Sensory Perception Completely limited Unresponsive to painful stimuli, due to diminished LOC or sedation or limited ability to feel pain over most of the body Very Limited Responds only to painful stimuli, cannot communicate discomfort except by moaning or restlessness or No impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. Moisture Constantly moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned Bedfast Confined to bed Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned or Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day Chairfast Ability to walk severely limited or non-existent, cannot bear own weight and/or must be assisted into chair or wheelchair Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours Mobility Completely Immobile Does not make even slight changes in body or extremity position without assistance Very Limited Makes occasional changes in body position but unable to make significant changes Slightly Limited Makes frequent though slight changes in body position independently No limitation Makes major and frequent changes in position without assistance. Nutrition Very Poor Never eats a complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein per day. Takes fluids poorly. Does not take a liquid dietary supplement. Or NPO/clear liquids only for more than 5 days Problem Requires moderate to max assist in moving. Complete lift without sliding against sheets is impossible. Frequently slides down in bed Probably Inadequate Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. May receive less than optimum tube feeding Potential Problem Moves feebly or requires minimal assist. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Adequate Eats over half of most meals. Eats a total of 4 servings of protein per day. Occasionally will refuse a meal but will usually take a supplement. May be on tube feeding or TPN Excellent Eats most of every meal. Never refuses a meal. Usually eats 4 or more proteins. Occasionally eats between meals and does not require supplement. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. Total Score Activity Friction and Shear Rarely Moist Skin is usually dry, linen only requires changing at routine intervals 20 If your patient is at risk for skin breakdown, you should include it as a nursing problem. Answer the question on the next page—- No Risk > 19; At Risk = 15 – 18; Moderate Risk = 13 – 14; High Risk = 10 – 12; Very High Risk = 9 or less 7 Braden Scale- What does the score mean? Part 2: CLINICAL REASONING Identify THE TOP 3 nursing problems and the data to support the choices. Place in priority order. IDENTIFIED PROBLEMS (in the Nursing context) SUPPORTING DATA (history, medication, head-to-toe assessment findings-provide related abnormal and normal findings, laboratory and diagnostic assessment) Impaired tissue integrity R/T surgical procedure Abdominal surgical incision, midline 12 cm long closed with staples. 8 PART 2. NURSING PROBLEMS AND PRIORITIES (use Care Plan reference)– Complete POST clinical Priority #1 Nursing diagnosis: (Problem) R/T: As evidenced by: SMART Goal: Patient will Nursing Interventions (list ALL possible even if you did not complete) 1. 2. 3. 4. 5. 6. Rationale & reference for Nursing Interventions (specific to THIS patient) 1. 2. 3. 4. 5. 6. Reference APA format Outcome/Evaluation of goal #1: State what you would do differently even if goal was met: 9 Priority #2 Nursing diagnosis: (Problem) R/T: As evidenced by: SMART Goal: Patient will Nursing Interventions (list ALL possible even if you did not complete) 1. 2. 3. 4. 5. 6. Rationale & reference for Nursing Interventions (specific to THIS patient) 1. 2. 3. 4. 5. 6. Reference APA format Outcome/Evaluation of goal #2: State what you would do differently even if goal was met: PART 3. REFLECTIONS – complete POST-CLINICAL (you may use the backside for more space) 1. Describe your thoughts and feelings about caring for your patient today. How did you feel about interacting with the patient, family, and staff? 2. How effectively did you carry out your intended plan of care? What were some of the barriers you faced? How did you overcome those barriers? 3. What would you do differently if you could “do” this shift over again? 4. Describe something new that you learned today. 10 Change of shift report. SBAR SITUATION • Biographical data BACKGROUND • Patient history ASSESSMENT • Diagnostic • Nursing assessment RECOMMENDATION • Nursing Care 11

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