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8/17/2019 Care Plan Data Collection
1/14
Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Student Name: _________________________ Clinical Site: _________________ Date: ___________
Patient Initials: Age:
Sex:
Code Status:
Primary Diagnosis:
Past Medical History:
Past Surgical History:
Primary Doctor:
Consults:
Admission thru: __ Direct Admit __ ER
__ Transfer from another hospital __ Transfer from another unit __ ther ________________________________
Pt from: __ Home __ !ong"term care #acility __ Psychiatric #acility __ S$illed %ursing #acility
Admission Date: Ht: &t: Allergies:
Vital Signs: Temp (+ route) _____ Pulse _____ P _______ !espirations ______ "# Sat ______ Pain le$el ______
Diet: ____________________________ Accuc%ec&(s): __________ ___________ ____________ __________
Data Collection Special'uipment
Inter$entions
Neurological (include pain mental status speec%)
Cardiac
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8/17/2019 Care Plan Data Collection
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
!espirator*
astrointestinal
enitourinar*
,usculos&eletal
S&in
2
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Ps*c%osocial
Intra$enous -ines (IVs)
Site auge StartDate
'xamination Inter$ention(s)
IV solution: !ate:
-a.orator* Studies and DiagnosticsTest Date Patient/s results 0%* does t%is
patient %a$e t%is$alue1
0%at does t%is mean2or *our patient1
0%at care orconsiderations 3ill *ou
implement1
CCHemoglobinHematocrit
PlateletsRBC’sWBC’sESRHgA1c
,PC,PGlucoseElectrolytesBUN AlbuminCreatinine!" #" SH
A/s$H" PaC%&HC%'!
PTTPT4IN! Platelets
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Drug -e$els
(igo)in*anco(ilantin+eo$+ylline
Cardiac,ar&ersro$onin,yoglobinC-',B" BNPE-G
-i$er5unctionA." AS
Amylase.i$ase"CH%."riglyceri/es.(." H(.
6rinal*sis
CulturesWoun/ Urine+roat
Bloo/78ra*!eports
CT and4or,!I/s
6ltrasound'c%o4"t%er
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
"perati$e !eports
,orse 5all Scale (9ospital)
5
STC-04-04- 2016
Ris$ !e'el
M#S Score
Action
Low Risk 0 - 24 Good Basic
NursingCare
ModerateRisk
25 - 50 Implementtandard
!all"re#entionInter#ention
s
$ig% Risk & 5' Implement$ig% Risk
!all"re#entionInter#ention
s
Item Scale Scoring
'( $istor) o* *alling+immediate or wit%in ,mont%s
No 0es 25
2( econdar) diagnosis No 0es '5
,( .m/ulator) aidBed restnurse assistCrutc%escanewalker !urniture
0'5,0
4( I1$eparin Lock No 0es 20
5( Gaitrans*erringNormal/edrestimmo/ile3eakImpaired
0'020
( Mental statusriented to own a/ilit)!orgets limitations
0'5
Total
8/17/2019 Care Plan Data Collection
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Hendrich (( #all Ris$ Model )Reha*+!TC,
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
-raden S$in Ris$ Scale
Sensory
Perception
./
Completely!imited
0/
1ery !imited
2/
Slightly!imited
3/
%o(mpairment
(ndicate Score:
Moisture ./
ConstantlyMoist
0/
1ery Moist
2/
ccasionallyMoist
3/
Rarely Moist
Acti'ity ./
-edfast
0/
Chairfast
2/
&al$sccasionally
3/
&al$s#re4uently
Mo*ility ./
Completely(mmo*ile
0/
1ery !imited
2/
Slightly!imited
3/
%o!imitations
%utrition ./
1ery Poor
0/
Pro*a*ly(nade4uate
2/
Ade4uate
3/
E5cellent
#riction
and Shear
./
Pro*lem
0/
PotentialPro*lem
2/
%o ApparentPro*lem
Total Score
%TE: Patients 6ith a total score of .7 or less are considered to *e at ris$ of de'eloping pressure ulcers/).8 or .7 9 lo6 ris$ .2 or .3 9 moderate ris$ .0 or less 9 high ris$,© Copyright Barbara Braden and Nancy Bergstrom, 1988
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
,edications
Allergies: __________________________________ ,edication Times: _________ _______ ____________
C%ec& VS C%ec& Pain -e$el C%ec& appropriate la.s C%ec& lood lucose
Name o2 ,edicationrand andeneric
Indication andP%armacological
class
Doseand
route
Sa2e14N
Possi.le Side '22ects(All common and serious;
,in < 2or eac% s*stem)
Nursing Considerations2or T9IS medication
(Assessment data la.s2ollo3 up)
Name o2 ,edication
rand andeneric
Indication andP%armacological
class
Doseand
route
Sa2e14N
Possi.le Side '22ects(All common and serious;
,in < 2or eac% s*stem)
Nursing Considerations2or T9IS medication
(Assessment data la.s2ollo3 up)
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Nurses/ Notes
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Date4Time Notes Signature
Nurses/ Notes
Date+Time %otes Signature
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
(nta$e and utputP (nta$e Enteral
(nta$e(1 (nta$e utput -M
Break*ast ime .mount6ml7
ime .mount6ml7
ime )pe .mount 6mL7 ime )pe .mo6mL
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
• Consumed
888888889
• !luids
8888888 mL
Lunc%
• Consumed
888888889
• !luids
8888888mL
:inner
• Consumed
888888889
• !luids
8888888mL
$ snack
• Consumed
888888889
• !luids
8888888mL
Is t%is patientrecei#ing enteralnutrition;es No
)pe 88888888888888888 88888888888888888
•
• u/ing C%ange<
888888888
=rine>mesis
:rain
Li?uid
!ormed
Colostom)
=rine>mesis
:rain
Li?uid
!ormedColostom
)
=rine>mesis
:rain
Li?uid
!ormedColostom
)
=rine>mesis
:rain
Li?uid
!ormedColostom
)
=rine>mesis
:rain
Li?uid
!ormedColostom
)
=rine>mesis
:rain
Total
Li?uid
!ormedColostom
)Total
Total Total
; (f patient is incontinent< please note 6hether the 'oid 6as scant< moderate< or copious/; Measure all #oley Catheter output )once a shift unless more often is necessary,/; Measure all drain output )once a shift,/; Measure li4uid stools and emesis 6hen a*le to contain
%e6 rders
1.
2.
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
3.
%ursing Diagnoses
%ursing Diagnosis: =oal: (nter'entions:
>./ ./
0/
./ )Assess,
0/ )Do,
2/ )Colla*orate,
3/ )Medication,
8/ )Safety,
7/ )Teach,
>0/ ./
0/
./ )Assess,
0/ )Do,
2/ )Colla*orate,
3/ )Medication,
8/ )Safety,
7/ )Teach,
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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)
>2/ ./
0/
./ )Assess,
0/ )Do,
2/ )Colla*orate,
3/ )Medication,
8/ )Safety,
7/ )Teach,
STC-04-04- 2016
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