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Rasmussen College Name: Date:

Care Plan #

Rasmussen College

Nursing Care Plan: Basic Conditioning Factors

A. Patient identifiers:

Age: Gender: Ht: Wt. Code Status:

Isolation:

Please don’t do this part

Health Status

Date of admission:

Activity level: Diet:

Fall risk (indicate reason)

Client’s description of health status

Allergies: (include type of reaction)

Please don’t do this part

Reason for admission:

Past medical history that relates to admission:

Please don’t do this part

Socio-cultural Orientation

Cultural and Ethnic Background with current practices:

Socialization:

Family system: (Support system)

Spiritual:

Patterns of living:

Development Stage (Erikson): Give the stage and rationale for your evaluation

Please don’t do this part that above

Healthcare systems elements (continued) ALLERGIES:

Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?

Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference

Normal Saline 400 mL (20mL/kg)

D5½ NS IV at 62mL/hr

CON
CEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis


Gastroenteritis


Vomiting, diarrhea, and dehydration

Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)

Complications

Treatment (Medical, medications, intervention and supportive)

Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)

Nursing Diagnosis

Problem statement: (NANDA)

Related to: (What is happening in the body to cause the issue?)

Manifested by: (Specific symptoms)

. Fill out LAB Chart in its entirety

LAB

Normal

Range

Critical

Value

Value

Clinical Significance:

Nursing Assessments/Interventions Required:

HEMATOLOGY

CBC

WB

RBC

HGB

HCT

PLATLETS

DIFF:

Polys

Bands

Lymphs

Mono’s

Eosin

CHEM 7

Glucose

Chloride

Sodium

Potassium

BUN

Creatinine

CO2

URINALYSIS

Color

Clarity

Sp. Gravity

pH

Protein

Glucose

Ketones

Bilirubin

Occ. Blood

Urobilogen

WBC

RBC

Epithelia

WBC

RBC

Epith Cell

Bacteria

Hyal Cast

Gran Cast

Leukocytes

Nitrite

STOOL O+P+

Culture

Giardia

Cryptosporidium

Entamoeba histolytica

REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HIS RESPONSE.

PLAN OF CARE: Use your top two priorities

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom)

Manifested by: (Specific symptoms)



Short term goal

: Create a SMART goal that relates to hospital stay/shift/day.



Long term goal
: Create a SMART goal that is appropriate for discharge.

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

Interventions for short-term goal:

1.

2.

3.

Interventions for longterm goal:

1.

2.

3.

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

Reassess for short-term goal:

1.

2.

3.

Reassess for long-term goal:

1.

2.

3.

Was it met or not met there is no partially met.

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom?)

Manifested by: (specific symptoms)

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

Was it met or not met there is no partially met.

complete Worksheet

Gastrointestinal Disorder Presentations (submit to the discussion board):

• Create a poster/PowerPoint on Constipation for a school-age child 5 to 8

• Include signs and symptoms

• What causes it

• Management of symptoms

• Medication that may be used

• Prevention

• Assessment findings

• What risk factors are associated with the disease process: (dehydration, electrolyte imbalance, . . .)

• What questions the nurse should ask the patient/family presenting with this illness

• Education to family.

This PowerPoint should be done separately

This assignment needs to be plagiarism free PLEASE

NO CONSIDERATION FOR PLAGIARISM

APA FORMAT AND INDEX CITATION, REFERENCE

PLEASE WRITE FROM A NURSING PERSPECTIVE

Pilot Summer 2016 KC 9

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