Florida Community College of Jacksonville

NUR 1022C: Nursing Care Plan for TERM 1

(rev 09/25/09)

Student Date of Care: Code Status

Client’s Initials Room # Age/Sex: Admit Date: Isolation Status

Allergies Activity Level Diet

Reason for Hospitalization

Admitting Diagnosis

Other Medical Diagnoses

Previous Surgery /Year: ( last 5 yrs)

Explanation of Admitting Diagnosis: (One-two sentence about in own words about the pathophysiology; Then, 3-5 of the signs and symptoms of
the medical disease process)

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 MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C

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 MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C

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 MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C

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Lab/Diagnostic Tests
List Normal Values for your
hospital below
WBC
LAB/DIAGNOSTIC TESTS
Purpose of Test Date and Results Implications for abnormals
Admission Most (why do you think your patient
had
Recent these abnormal values/what caused it
for this patient )

RBC

Hgb

Hct

Platelets

Glucose

Na

Ca

BUN

Creatinine

PT/INR

PTT

Other Labs

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 DIAGNOSTIC TESTS: Purpose of Test Date Results Implications for
X-rays, CT, MRI, US abnormals
12 lead EKG, ABG,
etc

Nursing Diagnoses (PES Format)

1. ___________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________

4. ____________________________________________________________________________________________________________
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Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

1. ___________________________________________________________________________________________________________

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Assessment Nursing Plan Nursing Orders Scientific Client
Diagnosis & Basis/Rat Respon
S=Supportive Data for Goals Short term/ Interven ionale for ses/
Nursing Diagnosis P=Client Problems long term
tions Action
(number in Evaluation
*List Assessment Data order of Desired Outcomes
priority) *Include source and page
List (5) interventions per
Subjective: number for each BE SPECIFIC!
(Use behavioral terms, problem identified.
Objective: intervention.
E=Pathophysiology/ specific &
measurable) Asterisk (*) those
psychosocial
interventions you
implemented during
clinical.

Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

2. ______________________________________________________________________________________________________
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Assessment Nursing Plan Nursing Orders Scientific Client
Diagnosis & Basis/Ra Respons
S=Supportive Data for Goals Short term/ Interven tionale es/
Nursing Diagnosis P=Client Problems long term
tions for
(number in
Action Evaluation
*List Assessment Data order of Desired Outcomes
priority) List (5) interventions per
Subjective: BE SPECIFIC!
(Use behavioral terms, problem identified. *Include source and page
Objective: specific & number for each
E=Pathophysiology/
measurable) Asterisk (*) those intervention.
psychosocial
interventions you
implemented during
clinical.

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Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

3. _______________________________________________________________________________________________________

Assessment Nursing Plan Nursing Orders Scientific Client

Diagnosis & Basis/Ra Respons
S=Supportive Data for Goals Short term/ Interven tionale es/
Nursing Diagnosis P=Client Problems long term
tions for
Action Evaluation
*List Assessment Data Desired Outcomes
E=Pathophysiology/
List (5) interventions per
Subjective: psychosocial BE SPECIFIC!
(Use behavioral terms, problem identified. *Include source and page
Objective: specific & number for each
measurable) Asterisk (*) those intervention.
interventions you
implemented during
clinical.

10
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Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

4.___________________________________________________________________________________________________________

Assessment Nursing Plan Nursing Orders Scientific Client

Diagnosis & Basis/Ra Respons
S=Supportive Data for Goals Short term/ Interven tionale es/
Nursing Diagnosis P=Client Problems long term
tions for
(number in
Action Evaluation
*List Assessment Data order of Desired Outcomes
priority) List (5) interventions per
Subjective: BE SPECIFIC!
(Use behavioral terms, problem identified. *Include source and page
Objective: specific & number for each
E=Pathophysiology/
measurable) Asterisk (*) those intervention.
psychosocial
interventions you
implemented during
clinical.

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 PHYSICAL ASSESSMENT
Circle and describe appropriate responses. If abnormal, describe within this assessment form
Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

Describe general appearance: (Physical appearance, Body structure, Mobility, Behavior)

Ht ________ Wt __________________ BMI_____________(Normal = 18.5-24.9)

BMI= weight (in pounds) divided by height (in inches)2 x 703
State of nutrition: Underweight____ Overweight____ Obese____ (>30)

PAIN Onset and duration:

Location (specify anatomical site):

Severity (use 0-10 pain scale):

Precipitating or aggravating factors:

Pain med given ? What med, dose, route? What time?

Effective? . No  Yes  (Describe how you can tell this)

NEURO Oriented to: time, person, place. Describe behavior if disoriented:

MENTAL
Any: Numbness, tingling, vertigo, syncope, headache, tremors, seizures, memory loss, aphasia/verbal behaviors, inattentive, agitation. No
STATUS
 Yes  Circle term &describe):

Cooperative: No  Yes  (describe):

Level of sedation (Glascow Coma Scale):

Best eye opening response?
Best motor response?
Best Verbal response?

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 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

SKIN or Skin Temperature: warm, cool, dry, clammy,__________

WOUND
Skin characteristics: edema, blanching, cyanosis, pallor, jaundice, hyperemia, ecchymosis, petechiae, bleeding, cuts, boils, decubiti,
drainage, diaphoresis; rash, hematoma, nail changes.
Skin turgor/ Pinch test findings:

Describe hair color, condition & distribution:

Tattoos , piercings scars: Specific anatomical locations)

Wound Sites (Specific anatomical locations)

Dressings (Specific anatomical location , dressing composition, status):

Drains/Drainage (type and location):

EYES Vision loss, glasses, contact lens, excessive tearing, sty, exophthalmus, cataracts, artificial eye, ptosis, discharge
(describe)______________________________________ other: _______________________________
Test PERRLA ? No  Yes  Findings?
Test 6 Cardinal Positions of Gaze? No  Yes  Findings?
NOSE Rhinitis, epistaxis, loss of sense of smell, sneezing , discharge, irritation, other:_____________________
Septum midline: No  Yes  Nares patent: No  Yes 
EARS Deafness, hearing aid, discharge, tinnitus, other:_____________________
Whisper Test? No  Yes 
MOUTH, Dentures Bleeding gums, caries, implants, speech impediment, goiter, throat irritation, lesions; lips, gums, halitosis , Dysphagia,
THROAT Dysphasia, Tracheostomy, Hoarseness
& NECK Able to speak, bite, chew, swallow, taste; If any No, describe______
Lymph node enlargement? No  Yes (where)

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 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

Uvula midline? Move anterior when says “ahh”? No  Yes 

Tongue thrust midline? No  Yes 

RESPIR Respirations: shallow, irregular, regular, irregular, other:____________

ATORY Nocturnal dyspnea, dyspnea on exertion, orthopnea unequal chest expansion, Tactile fremitus Cough: dry,
wet, productive, nonproductive; hemoptysis,
Lung sounds Anterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____;
Lung sounds Posterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____; crackles ? _____ Where heard?
_________ wheezes? _____ Where heard? _________

Oxygen _____L/min Device: (type)______________________ Pulse Ox _________%

Incentive spirometer ______________ave._mL . Nebulizer ? _______ MDI? ______

CARDIO Heart Rate: apical_____ Rhythm: regular____ irregular___

VASCU Pulse deficit (Apical_____ minus radial______) PD________
LAR
Pulse Pressure: (Systolic)________minus Diastolic ______= PP______________
Peripheral pulses Present RIGHT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________
Peripheral pulses Present LEFT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________

Edema: RIGHT pitting______ non-pitting_____ ; LEFT pitting______ non-pitting_____

Capillary refill_______ seconds; Lower extremity temp _________ and color: _________________

GAS Nausea, vomiting, dysphagia, anorexia, polydipsia, heartburn, ascites, constipation, diarrhea, abdominal distention, flatulence, tarry stool,
mucous stools, hemorrhoids, rectal bleeding, pain, incontinence, hernia, weight loss/gain
TRO-
INTES Date last B.M and characteristics: ___________________________________
TINAL
% of diet eaten: ____________________food intolerance ________________

Bowel sounds present RLQ? ________ RUQ?________ LUQ? ________ LLQ? ______________
NG tube_______ G tube_______ J tube_______ Ostomy_______

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 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

GENI Urine:color____________, clear, cloudy, Foley, Suprapubic catheter, CBI, dysuria, polyuria, oliguria, hematuria, nocturia, incontinence, flank
pain UTI, albuminuria, glucosuria, dribbling, hesitancy, frequency, burning, other
TO-
(specify)______________________________________________
URIN
ARY
Intake: previous 24 hrs. _________ During care: PO/Tube ____________cc IV_____________cc

Output: previous 24 hrs. ________ During care:urine________________CC other`(specify) ______

MUS Joint pain, arthritis, gout, claudication, varicose veins, paralysis, contractures, deformities, amputations, unsteady gait.
CULO- Describe ROM and strength in each extremity (0-5 scale):
SKE Head & Neck____; R arm_________; L arm_______; R leg__________; L leg____________
LETAL
Describe activity tolerance:

Describe ability to ambulate/ gait:

IV/ IV site(s) ____________________________ -__________________________________

INFUS
IV type(s)_______________________Rate_____ ; _______________________________ Rate _____
ION &
CATH IV needle gauge?______ Date inserted: __________ Site condition: ___________________________
ETERS
Tubing change date: ______________ IV Site care given: No  Yes 

THERA Walker, crutches, cane, trapeze, prosthesis, wheelchair, scooter, CPM,SCDs, TEDs, Heating pad, Ice pack, bed fall monitor, therapeutic
PEUTIC
bed, wound VACs, PCA pump, cooling/heating blanket,
Or
ASSISTIVE Implants: ___________________________________________________
DEVICES

DOCUMENTATION (Your Nurses Notes defining care given)

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