PATIENT CARE PLAN GENERIC SURGICAL- Betty Graham

The Care Plan outlined below was created for Betty Graham on Tuesday
the 5th of May 2016 at 1330 hrs, after her admission to ward 1A from post
recovery. The care plan was written with the best available information,
obtained from the handover. A time management grid is also included that
highlights the planning done for that particular shift till 2200 hrs.

Her Waterlow Pressure Area Risk Assesment Score was determined to be 6

Issues Guidelines Date- 5/05/16 Date
for
Assesment
Nutrition/Hydra Full Diet
tion
Elimination Continent-
Bowel chart
Intravenous Yes- IV Fluids
Therapy
Mobility Assist X1
(Due to
attached drain
and to minimise
pulling)
Hygiene Set up Assist
(Until further
assessment shows
independence)
Oxygen 3L via NP
Therapy
Pain/Nausea PRN
management
analgesia
Anticoagulant TEDS
Therapy
stocking (As a
preventative
measure, due to
more time spent
in bed and age)
Diabetes Not
management
applicable
General SAG0 4/24
observations 1/24 UWSD
2/24 Neuro obs
Tests/Investigati -Monitor UWSD
ons drainage
-Neuro obs
Referrals -Physiotherapy
for coughing
exercise
-D/C planner
-Social worker
Drug and N/A
alcohol
Discharge N/A
planning
ID Band If ID Band missing In Situ- Yes,
or incorrect please Right arm.
action
appropriately
Skin -General Waterlow score
condition
6.
-Waterlow score
-Strategies
Skin description
implemented (record heavy
-Pressure Area lettering only and
site Intact
4th
hrly pressure
area care
Mattress Type
Standard
INTERVENTIONAL
STRATEGIES
A B C D
Pressure Area- NO
Notification Sticker-
NO
Wound chart- Yes

Falls Risk Daily risk Score NA..

Assesment assessment Interventional
Interventional Strategies
strategies
Low Medium
High
Bedrail Position
UP
Restraints NO
Restraints Chart
NO
Supervision
NO
AM Signature, Print
name,
Designation
PM Signature, Print DhirenRabadia
name,
n, Dhiren
Designation
Rabadia
(Student
Nurse)
ND Signature, Print
name,
Designation

Time Management Template

Patient Name: Betty Graham

Shift: PM

Time Planned Intervention

Patient handover received.
1500 OBS, uwsd and neuro
Quick bedside orientation.
Administer PRN Oxycodone.
Patient skin assessment for any pressure area
1530 Change Dressing after PRN analgesia to reduc
IV saline at 80ml/hr.
Ring Neighbour about cat
1600 UWSD Observations
Referrals to physio, social worker and dischar
Order Full diet

1700 UWSD Observations

Neuro Obs

1800 IV/PO Meds- Paracetamol 1g

UWSD Observations
Check diet tolerance plus set up assist for din
1900 General Obs and pain assessment
UWSD Observations
Neuro Obs

2000 UWSD Observations

2100 UWSD observations

 Neuro obs
Check and update fluid balance chart
2200 UWSD observations
Prepare Patient Handover for night shift
Update care plan
Progress Notes

2230 Shift Completed