Posted: August 2nd, 2022

Nursing Care Plan: Basic Conditioning

                      Nursing Care Plan: Basic Conditioning Factors                                                         
A. Patient identifiers:

Age:                   Gender:                   Ht:               Wt.             Code Status:

Isolation:

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

 

 

Health Status
Date of admission:

Activity level:                                                                Diet:

Fall risk (indicate reason)

 

Client’s description of health status

 

 

 

Allergies: (include type of reaction)

 

 

 

Reason for admission:

 

 

 

 

 

Past medical history that relates to admission:

Socio-cultural Orientation
Cultural and Ethnic Background with current practices:

 

Socialization:

 

Family system: (Support system)

 

Spiritual:

 

Occupation: (across the lifespan)

 

Patterns of living: (define past and current)

 

Barriers to independent living:

 

 

 

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

 

Oxytocin

 

Carboprost (Hemabate)

 

Methergine

 

Misoprostol (Cytotec)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAB Normal Range Value/ Date Clinical Significance Nursing Assessments/ Interventions Required
HEMATOLOGY
CBC
WBC
RBC
HGB
HCT
PLATLETS
Diff:
Polys
Bands
Lymphs
Mono’s
Eosin
GBC indices
MCV
MCH
MCHC
 

SEROLOGY

HIV
GBS
Gonorrhea/ Chlamydia
Syphilis
Hepatitis B
Rubella
BLOOD TYPE
RH FACTOR

 

 

 

Universal Self-Care Deficits:    Assessment: (Highlight all abnormal assessment findings)
Vital Signs Admission Reassess
Input:
Output:

 

Cardiovascular Assessment:

Specialty devices:

 

 

 

Teaching needs:

Heart Sounds:

 

 

Circulatory Assessment:

 

 

Edema:

Pain assessment: (PQRST)- Specific area
Respiratory assessment

Special devices:

 

 

 

 

Teaching Needs:

Lung sounds:

 

 

Pulmonary assessment: (respiratory pattern)

Cough:

 

 

 

Respiratory treatment and rational for use:

Breast assessment:

 

 

 

 

 

 

Teaching Needs:

Breast Assessment:

 

 

 

 

Nipple assessment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breastfeeding plans:

 

 

 

 

 

Uterine Assessment:

 

 

 

 

 

Teaching needs:

Location:

 

Firmness:

 

 

GI Assessment:

 

 

 

 

Teaching needs:

 

 

GI assessment: (observe – auscultate –  palpate)

 

 

 

Alteration in eating or elimination patterns:

 

Nutrition Metabolic Assessment:

 

 

% of diet taken:

 

Alternative nutritional methods:

 

GU assessment:

 

 

 

Teaching needs:

Last void:

Due to void:

Alternative urinary elimination method: (if Foley when inserted)

 

Bladder scan

Assessment of urinary patterns:

Urine assessment (color odor concentration etc.)

 

 

 

 

Lochia Assessment:

 

 

 

Teaching needs:

 

 

Color:

 

Quantity:

 

Presence of clots:

Perineal Assessment:

 

 

 

 

Teaching needs:

 

REEDA:

 

 

 

 

 

 

Wound Care:

 

 

 

Thrombophlebitis Assessment:

 

 

 

Teaching needs:

 

 

 

Edema Assessment:

 

 

Teaching needs:

 

 

Emotional Assessment:

 

 

Teaching needs:

 

 

Edinburgh Postnatal

Depression Screening:

IV Therapies:

IV fluids infusing

 

IV Site 1: Assessment

 

Date of insertion:                   Change (site or dressing)

 

IV removal: Reason for removal:

Additional information:

 

 

 

 

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 HER RESPONSE.

 

 

 

CONCEPT MAP-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Process Care Plan (Example)

Assessment/recognize cues (what is outside normal limits, use measurements)

What data are relevant and must be interpreted as clinically significant by the nurse?

 

 

Nsg Diagnosis (not medical diagnosis)/ analyze cues –interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far? Prioritize a hypothesis/ Create a Plan and rationale:

(to do first-which one is the most pressing and why? Rank them by urgency: What problem is most likely present? Most concerning?

Generate solutions/goals (what level of improvement are we working towards, make it measurable) collect additional data? Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve? Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Was our goal met? Did our intervention help? What additional clinical decisions need to be made
Assessment #1

 

Patient reports SOB (subjective data)

 

 

Nsg Diagnosis

 

Impaired gas exchange? Impaired airway? need to obtain

O2 (84%)

RR (24)

lung sounds (exp wheezes)

Plan:

#1 is most concerning due to ABCs matrix)

Goals

 

improve oxygenation

Is this an airway issue-blockage?

Discover client has history of COPD, had pneumonia two months ago,

Intervention #1a

Raise HOB to 45-90 to improve lung expansion

Evaluation #1:

O2 trended up to 89% on 2L

RR trended to 22

Lung sounds cleared with coughing but wheezing returns with bedrest.

Goal partially met

 

Need to call provider with findings, request CXR, and foresee possible Antibiotics

Intervention #1b

NC 2L O2 to increase oxygen saturation of inhalation

Intervention #3c

Education about TCDB q1 hour while awake to clear the airways for better ventilation

Assessment #2

 

 

Patient reports pain 4/10

Nsg Diagnosis

 

etc

Plan:

 

etc

Goals

 

etc

 

Intervention #2a

 

 

Evaluation #2:
Intervention #2b

 

 

Intervention #2c

 

 

Assessment #3

 

Patient has new redness to coccyx

Nsg Diagnosis

 

etc

 

Plan:

 

etc

Goals

 

etc

 

Intervention #3a

 

 

Evaluation #3:
Intervention #3b

 

Intervention #3c

 

 

Nursing Process Care Plan For Client in Student’s Care (observe, take note, create

Assessment/recognize cues (what is outside normal limits, use measurements)

What data are relevant and must be interpreted as clinically significant by the nurse?

 

 

Nsg Diagnosis (not medical diagnosis) /analyze cues -interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far? Prioritize a hypothesis/Plan and rationale:

(which are we doing first-which one is the most pressing and why? Rank them by urgency? What problem is most likely present? Most concerning?

Generate solutions/goals ((what level of improvement are we working towards, make it measurable) collect additional data? Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve? Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Did our intervention help? What additional clinical decisions need to be made
Assessment #1

 

 

 

Nsg Diagnosis

 

 

Plan:

 

 

 

 

Intervention #1a

 

 

Evaluation #1:

 

 

Intervention #1b

 

 

Intervention #1c

 

 

Assessment #2

 

 

 

Nsg Diagnosis

 

Plan:   Intervention #2a

 

 

Evaluation #2:
Intervention #2b

 

 

Intervention #2c

 

 

Assessment #3

 

 

Nsg Diagnosis

 

Plan:   Intervention #3a

 

 

Evaluation #3:
Intervention #3b

 

Intervention #3c

 

 

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