Care Plan Data Sheets On

MEDTECH COLLEGE SCHOOL OF NURSING

CARE PLAN DATA SHEET NURSING PROCESS

Student Name_____________________________________ Course_________________________________ Date________________________

Assessment Additional Notes:

1. Client Data Base:Patient Initials: ________________Age: ______Gender:_____________ _____________________________________________

Cultural/Ethnic: _____________________________________________ _____________________________________________

Language Spoken: __________________________________________ _____________________________________________

2. Medical Data:Reason for hospitalization: ____________________________________ _____________________________________________

Medical Diagnosis: __________________________________________ _____________________________________________

Other existing problems______________________________________ _____________________________________________

Events leading to hospitalization: _______________________________ _____________________________________________

Summary of present hospitalization: _____________________________ _____________________________________________

Past Medical/Surgical History: _____________________________________________________________________________________

Diagnostic tests/procedures done during this hospitalization and the results:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Assessment Tool Nursing Diagnosis

Laboratory test results only for abnormal results. Please indicate why they are abnormal also indicate the norms and what the norm results indicate.

Lab Test Performed Results (Abnormal and the normal ranges) Why Abnormal

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Use the Assessment Tool in head-to-toe format and record information for both the physical and functional assessment data. _____________________________________

Data Collection_____________________________________

Vital Signs T_______ P_______ R_______ BP_____/____ HT_______WT____________________________________________

Head and Neck:_____________________________________

Mental Status: ______________________________________________________________________

Scalp: _____Clear _________________________________________ _____Dry _________________________________________ _____Other__________________________________________________________________

_____________________________________Hair: _____Clean

_________________________________________ _____Dirty

___________________________________________Face: _____Symmetrical

________________________________________________Asymmetrical

Eyes: _____Clear, no secretions _____Other____________________________________________ ___________________________________________

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Neck: _____Smooth, non-tender___________________________________________

_____Neck distention___________________________________________

_____Tender___________________________________________

_____large palpable lymph nodes___________________________________________

Ears: _____No drainage/lesions___________________________________________

Mouth:Gums: _____Moist, pink

________________________________________________Pale

________________________________________________Inflamed

________________________________________________Bleeding

________________________________________________Ulcers

___________________________________________Tongue: _____Moist, pink

________________________________________________Reddened

________________________________________________Cyanotic

_____Pallor ___________________________________________

_____Lesions present ___________________________________________

_____white patches ___________________________________________

Teeth: _____Complete _____Color: Clean, white Discolored _____Dental Caries

_____Loose tooth _____Missing tooth ____Dentures ___________________________________________

Mucous membrane: _____Moist ___________________________________________

_____Dry ___________________________________________

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Self Care: ______________________________________

_____Able to provide self-care (feeding, bathing/hygiene, dressing/grooming, toileting) ___________________________________________

_____Needs assistance with care: __________________________________________ ___________________________________________

_____Unable to provide self-care ___________________________________________

___________________________________________Comfort, Rest, Sleep

_____Has problems falling asleep___________________________________________

_____Requires sleeping pills

_____Naps sleeps during the day ___________________________________________

_____Pain present_________________________________________________ ___________________________________________(Specify level of pain, scale of 1-10)

What sleep pattern is expected for a patient of this age? ________________________ ___________________________________________

What is the actual rest pattern in your patient? _______________________________________ __________________________________________

Self-Perception/Self Concept:What is expected for a patient of this age? __________________________________________ ___________________________________________

What is actual self-concept of your patient? _________________________________________ ___________________________________________

Safety: Physical/Mechanical/Microbial/Chemical: ______________________________________

_____Risk for falls: _____History of falls: _____Sensorial deficit __________________________________________

_____Coordination deficit: _____Effect of narcotics/sedatives __________________________________________

_____Environmental hazards: clutter in room, poor lighting __________________________________________

_____Visual deficits __________________________________________

_____Presence of infection: ____________________________________________ __________________________________________

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Cardiovascular: Heart Sounds: Clear Muffled Murmur Thrills Hum S1 S2 S3

Right Peripheral Pulses: Carotid Apical Brachial Radial Groin Popliteal Posterior Tibial Pedal

Left Peripheral Pulses: Carotid Apical Brachial Radial Groin Popliteal Posterior Tibial Pedal

RUE Peripheral Capillary Refill </= 3 secs >3secs (Amount)

LUE Peripheral Capillary Refill </= 3secs >3secs (Amount)

RLE ________________________ LLE ___________________________________________ __________________________________________

Clubbing or Edema: _____________ Present & Location ________________________________ ___________________________________________

Cardiac Rhythm: NSR Irregular _____________________________________________ ___________________________________________

Tubes/site/location ____________________ Drains/site/location__________________________ ___________________________________________

Respiratory: Chest Expansion: Symmetrical/ Asymmetrical

R Breath Sounds: Clear Abnormal/Explain L Breath Sounds: Clear Abnormal/Explain: _____________________________________________________________ __________________________________________

Retractions: Mild Moderate Severe Intercostal Subcostal Sternal Substernal

Breathing Pattern: Regular/ Irregular, Unlabored/Labored, Shallow/Deep Dyspnea/Orthopnea/Apnea/Tachypnea Nasal Flaring

Cough: None/Non Productive/Productive & Color of expectorant, Amt: Scant, moderate, heavy

Assistive Device(s): Airway/type/size Tubes/site/location Drains/site/location (circle)

Integumentary:Skin: Intactness __________________________________________

Lesions: Macule, vesicle, nodules, pustule, papule, wheal, tumor (circle)

Texture, Temperature, Moisture: _____Smooth and soft _____Rough, thick, scaly _________________________________________

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_____Warm and dry _____Extremely cool or warm/hot diaphoretic _________________________________________Turgor and elasticity: _____________ _________________________________________

_____Pinched-up skin returns immediately to original position, elastic _____Pinched-up skin takes >=30 seconds to return to original position, inelastic

Infestations: _________________________________________

_____None _____Present____________________ _________________________________________

Nails: _________________________________________

_____Round, firm, smooth edges, pinkish 160 degree nail base _________________________________________

_____Clubbing: 180 degree or more nail base _________________________________________

_____Pale, cyanotic, splintered nails _________________________________________

_____Other: ___________________________________________________________ _________________________________________

Digestive/Gastrointestinal/Nutrition: _____________________________________Size and contour of abdomen:

__________________________________________Flat/soft/firm _____Distended

______________________________________________Enlarged _____Tender

______________________________________Bowel sounds on auscultation in all 4 quadrants (for up to 5 minutes in each quadrant)Frequency and characteristics: _____________ __________________________________________

_____Audible all 4 quadrants, high pitched, irregular gurgles 5 to 35 times/minutes __________________________________________

_____Hypoactive_____________________________quadrant____________________ __________________________________________

_____Absent________________________________quadrant____________________ __________________________________________

Bowel Movement: _____ Regular _____Irregular Date of last bowel movement: _________________ ___________________________________________

Characteristics of stools: _________________________________________________ ___________________________________________

Abdominal girth (if appropriate) ____________________________________________ ___________________________________________

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Diet: _______________%Eaten______________Snacks_____No_______Yes______ ___________________________________________

Food allergy: _____None______Yes________________________________________ ___________________________________________

Factors that may alter nutritional intake less or more than body requirements: ___________________________________________

_____________________________________________________________________ ___________________________________________Specify factors

___________________________________________Weight in relation to height________________________________________________

___________________________________________Signs of nutritional deficit (list) _________, _________, _________, _________, _____

___________________________________________Fluid intake in 24 hours (amount):

___________________________________________P.O._________________________________________________________________

___________________________________________Parenteral: IV_________________________________________________________

___________________________________________Rate of administration (CC’s/hr) ___________________________________________

___________________________________________Signs of fluid volume deficit/excess (specify below):

___________________________________________Skin turgor_____________________Mucous membranes______________________

Edema_____________________Urine characteristics_________________________ ___________________________________________

Feeding tube to be used: ______None ______Gastrostomy T. ______Jejunostomy T. ___________________________________________

Drainage tube: ______N.G. ______Cecostomy ______Ileostomy ______Colostomy ___________________________________________

Family Dynamics: Describe family interactions you observed:

_________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

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MedTech College School of NursingNursing Care Plan

Prioritized Nursing Diagnosis Goal/Expect Patient Outcome(Short-term goal, By end of shift, objective, measurable criteria) Include date and time

Nursing Interventions and RationaleNursing actions and frequency done during your care) Reasons for your actions

Evaluation/RecommendationDid patient reach goal? How do you know? What do you recommend for the next nursing shift?

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Related to:

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MedTech College School of NursingDrug Sheet

Medicine-Drug Dosage and Frequency of Administration

Classification Common Side-Effects Rationale for Use by Client

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MedTech College School of NursingClinical Skills Expectation Summary

Student Name______________________ Date__________________________________

Clinical Skill Expectation Instructor Signature Date Observed

Care Plan # Completed_____________________

Write in skill…example, “Communication /Patient education”

Write in skill

Write in skill

Write in skill

Write in skill

Write in skill

Write in skill

Comments:

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Documents

Care Plan Data Sheets On