ELGIN COMMUNITY COLLEGE NURSING CAREPLAN

INSTRUCTOR: ______________________________________ STUDENT CODE (Last page) __________ (MARK AN X IF COMPLETED) Pt AGE: DATE: ____ Section A (Sat) __ Section B (Thurs) ___ ___ Pt GENDER: ________

After receiving your careplan back from LEVEL 1, SEMESTER 1 if requested) to all feedback before returning careplan to class folder. Keep all carep your instructor, initial (or respond BOHNE STUDENT NAME: ____________________________________

MY INITIAL SUBJECTIVE CLINICAL IMPRESSION OF MY PATIENT:

PATIENT EXPECTATIONS REGARDING CARE:

CHIEF COMPLAINT UPON ADMISSION:

Admission Date:_____________

PAST MEDICAL & SURGICAL HISTORY (DEFINITON & SUMMARY & DATES)

ALLERGIES: ____________________________________________________________ CURRENT MEDICAL DIAGNOSES & SURGERIES/PROCEDURES (DATES) DEFINITION & SUMMARIES

DISCHARGE PLANNING NEEDS: (Where pt. will be going & what they need to know and/or have before they leave the hospital)

SELF-EVALUATION OF CLINICAL EXPERIENCE: USE CLINICAL EVALUATION TOOL AS REFERENCE FOR THIS SECTION. ADDRESS EACH OBJECTIVE SEPARATELY AND GIVE EXAMPLES.
Demonstrated growth in caring for self & Others Applied the nursing process Implemented nursing care thru provider & manager of care roles Practiced according to agency policy Provided holistic nursing care..

This form must be used when discuss meds with instructor that you pass in clinical

NURSING PROCESS: MEDICATION INFORMATION MEDICATION INFORMATION

Applying the Nursing Process to the Administration of Medications MEDICATION
Drug Bk.:_________ Page: ________

ASSESSMENTS
*Pt. data to collect before (initial
dose) and after (Ongoing) the drug is given.

EXPECTED OUTCOMES
Expected specific measurable outcomes for therapeutic action vs. patient teaching.

INTERVENTIONS
List the MAR order: medication, dose, route, & schedule; & Nursing implications. Specify patient teaching for shift/discharge. Medication administration 1. 2.

EVALUATION
After drug given:
Was outcome met? Were there adverse effects

generic name (Trade name)

Arrange in 2 categories: 1) What data should be collected before the first dose is ever taken?

Therapeutic: Pt. will

A.

Evaluate after onset: Response R/T Therapeutic Outcomes:

MAR order:

Classifications:

Usual Dose Range, routes/schedule & frequency:

Nursing implications in administrating the medication;

.
2) What data should be collected in a patient who has been taking this drug? (VS, labs, test prep)

B.

Evaluate for Side/Adverse Effects: (Were there any adverse effects?)

Action: List possible Adverse effects (bold or italicized in drug book).

None observed;

____

If yes, which effects were observed?

Use:

Teaching: (What does pt. know about medication?)

Teaching:

Teaching:

Teaching Response:

NUR 116/Medication Information BLANK/ revised 10.2010

This form must be used when discuss meds with instructor that you pass in clinical

NURSING PROCESS: MEDICATION INFORMATION MEDICATION INFORMATION

Applying the Nursing Process to the Administration of Medications MEDICATION
Drug Bk.:_________ Page: ________

ASSESSMENTS
*Pt. data to collect before (initial
dose) and after (Ongoing) the drug is given.

EXPECTED OUTCOMES
Expected specific measurable outcomes for therapeutic action vs. patient teaching.

INTERVENTIONS
List the MAR order: medication, dose, route, & schedule; & Nursing implications. Specify patient teaching for shift/discharge. Medication administration 3. 4.

EVALUATION
After drug given:
Was outcome met? Were there adverse effects

generic name (Trade name)

Arrange in 2 categories: 3) What data should be collected before the first dose is ever taken?

Therapeutic: Pt. will

C.

Evaluate after onset: Response R/T Therapeutic Outcomes:

MAR order:

Classifications:

Usual Dose Range, routes/schedule & frequency:

Nursing implications in administrating the medication;

.
4) What data should be collected in a patient who has been taking this drug? (VS, labs, test prep)

D.

Evaluate for Side/Adverse Effects: (Were there any adverse effects?)

Action: List possible Adverse effects (bold or italicized in drug book).

None observed;

____

If yes, which effects were observed?

Use:

Teaching: (What does pt. know about medication?)

Teaching:

Teaching:

Teaching Response:

NUR 116/Medication Information BLANK/ revised 10.2010

DATA
DEVELOPMENTAL: REQUIRED FOR EVERY
PT. SELF CARE BEHAVIORS RISK FACTORS Erikson's stage of G & D (which & why) Havighurst's developmental tasks for stage variations / influencing factors r/t dev tasks; impact of illness/hospitalization on dev tasks -Older adult: evidence of gerotranscendence? Other:

DESCRIPTION OF DATA

Nsg Dx / Interventions ( Meds & Sci Rat) / Exp Outcomes/ Evaluation

Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:

Interventions (include meds & scientific rationale):

EMOTIONAL
SELF CARE BEHAVIORS RISK FACTORS MEDICATION INFLUENCES willingness/reliabilityto provide history stressors currently affecting this person past experiences that may influence stress / adaptation - losses / suffering / stage of grief (include supportive data) / end of life issues - adaptation / coping skills / defense mechanisms - emotional responses to recent circumstances - ability to self-advocate Other:

Evaluation: (of expected outcomes)

SOCIOCULTURAL / SPIRITUAL
SELF CARE BEHAVIORS RISK FACTORS support system / significant others home situation work situation (affected by this illness?) influencing factors r/t cultural & religious beliefs leisure activities personal meaning of situation impact of situation on self-esteem / body image, sexuality what is important to this person

Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes:

Interventions (include meds & scientific rationale):

Other:

Evaluation: (of expected outcomes)

PAIN / DISCOMFORT
- SELF CARE BEHAVIORS - RISK FACTORS - MEDICATION INFLUENCES Sedation scale S, 1, 2, 3, 4 - pain / discomfort: Yes _____ No ______ - location, quality (pt's own words, if possible) - pain scale rating: (1-10) - pain goal: (1-10) - satisfaction with pain management: Yes____ No____ (if no, why not) - alleviating / aggravating factors - responses (behavioral, physiologic, affective) - meaning of pain / suffering - for non-self-reporting patient: Proxy (agent) report FLACC scale - Summarize pain relief interventions

Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes:

Interventions (include meds & scientific rationale):

currently being used & responses.

Other:

Evaluation: (of expected outcomes)

ENVIRONMENT
- SELF CARE BEHAVIORS - RISK FACTORS (knowledge, self-care behaviors) - neat, clean, orderly, disarranged, cluttered - type of equipment / supplies in room - light, temperature, ventilation, humidity, noise level, disturbances - access to needed items: personal items, call light, etc - home environment, if applicable (ex. if pt. fell or illness/surgery will affect ability to function in home or if home environment was a factor contributing to illness/hospitalization)

______________________________________
Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:

Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

Other:

IMMUNE RESPONSE
- SELF CARE BEHAVIORS

INFLAMMATION, INFECTION -RISK FACTORS: -MEDICATION INFLUENCES (NEGATIVE):

Nsg Dx: (additional on backcircle this statement to cue instructor)

- MEDICATION INFLUENCES (POSITIVE): - febrile, malaise, flushed, diaphoretic - Temp today: _______ (rte) _______ @ _____ - Temp Range: _______to _______ - WBC WNL, sed rate WNL: Dates: _________ - differential WNL - C& S - neg; site: ________________Date:___ Other: Results of labs include dates: WBC /date: __________ ( ) )

Exp. Outcomes: Interventions (include meds & scientific rationale):

sed rate /date: ___________ (

differential: ___________ - C & S: site__________positive for:____________ Date: ____________ - Sensitivity: _________________________ - Transmission-based precautions (type/reason)

_____________________________________ COGNITION
- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - LOC: alert: Yes ________ No ________ - orientation: person, place, time and recent events - speech appropriate: Yes _ ____ No ________ - able to articulate needs: Yes _______ No ______ - affect / mood appropriate: Yes ______ No ______ - responds appropriately to verbal / non- verbal stimuli: Yes_ __ No ____ - good historian Other: - MEDICATION INFLUENCES (-): - drowsy,lethargic,unable to follow directions(explain/ex): - disorientation: acute or chronic / degree (explain/ex) - short / long term memory loss (explain/ex): - slurred speech, garbled (duration): - aphasia (duration / explain): - inappropriate verbal / non-verbal response (describe/ex): - change in cognitive assessment (explain trends) -unable to provide history (explain): -who provides history? Other: - RISK FACTORS:

Evaluation: (of expected outcomes) Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes: Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

EYE / VISION

(Specify Right & Left)

- RISK FACTORS: - MEDICATION INFLUENCES(-): jaundice, redness, drainage, opaque lens, injected unequal shape and size pupil light response unequal, slow or absent impaired vision: recent changes:

Nsg Dx: (additional on backcircle this statement to cue instructor)

- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES(+): - sclera - white, lens clear PERLA, symmetrical blink - acuity WNL without supportive aid - acuity WNL with supportive aid - supportive aid: Yes __ No _____ describe: Other:

Exp. Outcomes: Interventions (include meds & scientific rationale):

Other:

Evaluation: (of expected outcomes)

______________________________________ EAR / HEARING (Specify Right & Left) -SELF CARE BEHAVIORS: -MEDICATION INFLUENCES (+):
-intact pinna -acuity WNL without aid -acuity WNL with aid -supportive aid Yes_____ Describe: Other:

_____________________________________ -RISK FACTORS: -MEDICATION INFLUENCES (-):

______________________________________________________________ _ Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:
No______ -excessive cerumen, redness, drainage -non-intact pinna -c/o pain (which ear?) -decreased hearing acuity (describe): -Other (eye / ear):

Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

___________________________________________ _ __________________________________________ - RISK FACTORS: - MEDICATION INFLUENCES (-): - lesions, cracks, drooping, cyanosis, dry - redness, edema, lesions, masses, bleeding, cyanosis, odor, white patches, ulcers - multiple caries, missing teeth, unclean - coated, white patches, ulcers, unsymmetrical movement - ill-fitting dentures: Other:

MOUTH
- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - lips: pink, intact, moist - mucosa and gums: pink, intact, moist - teeth: complete, white, clean - tongue: symmetrical movement, pink, midline - well-fitting dentures Upper Other: Lower ______

______________________________________________________________ _ Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:

Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

CARDIOPULMONARY: CARDIO
- SELF CARE BEHAVIORS:

- RISK FACTORS: - MEDICATION INFLUENCES (-):

Nsg Dx: (additional on backcircle this statement to cue instructor)

- MEDICATION INFLUENCES (+): B/P _____, P ___, AP _____ @ ___________ Range: B/P ___________, P: __________ Heart Tones S1, S2 heart: apical rhythm regular, distinct pulse deficit less than 2 peripheral pulses 2+-3+, equal bilaterally bradycardia, tachycardia, arrhythmia hypertension; unequal, bounding or thready pulse orthostatic hypotension pulse deficit more than 2: peripheral pulses unequal, weak:

Exp. Outcomes:

Interventions (include meds & scientific rationale):

- cyanosis, capillary refill sluggish - edema (location, grading, pitting): - calf tenderness (positive Homans) - neurovascular check abnormal: (specify /compare lt to rt)) Other:

- skin of extremities: pink, capillary refill < 3 sec., warm - no edema __________ - negative Homans sign -calves symmetrical

- neurovascular check: circulation, motion, temperature, sensation: WNL Other: ___________________________________________ _PULMONARY/CHEST - SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - R rate WNL (12-20) ____bpm @ ____________ - R range: _______________ - R regular, symmetrical chest expansion - R moderate depth, easy respirations, unlabored - breath sounds present, clear - skin, nail beds and oral mucosa pink - nasal patency - Neck circumference WNL Pulse Oximetry WNL (>94%) ______% @ _________ - Blood gases: WNL Date: _____ - Hgb WNL Date: _____ - Hct WNL Date: _____ - Chest X Ray (CXR) WNL Date: _____ - breasts: symmetrical, protruding nipples, skin intact Other:

Evaluation: (of expected outcomes)

___________________________________________ - RISK FACTORS: - MEDICATION INFLUENCES (-): - bradypnea, tachypnea - paradoxical, abdominal breathing, asymmetrical chest expansion - R shallow, SOB, dyspnea, orthopnea, activity intolerance - Lung sounds: crackles or rhonchi (fine, coarse, location) wheezes, diminished (Rt? Lt? bases? thruout) cyanosis or pallor of oral mucosa, lips, nail beds nasal drainage, obstruction use of O2 (mode of delivery; liter flow): cough: productive / non-productive sputum (color, amount, consistency): ______________________________________________________________________ _

Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:

Interventions (include meds & scientific rationale):

Pulse ox _______ - Blood gases/date: ____________ - Hgb/date: ___________ ( ) Norm - Hct/date: ____________ ( ) Norm - CXR/date: ___________ - breasts: asymmetrical, nipple retraction, discharge, dimpling, hx of lumps Other:

Evaluation: (of expected outcomes)

11

ABDOMEN / BOWEL
- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): bowel sounds active x 4 abdomen soft , flat, non-tender percussion: tympany brown, soft, formed stools, easily passed, flatus usual elimination pattern: ___________

- RISK FACTORS: - MEDICATION INFLUENCES (-): - high pitched, hypoactive, absent, hyperactive - abdominal distention, firm, tender/pain: - abdominal size/striae/ascites - percussion: hyperresonance, dull, flat: - constipation, no flatus, excess flatus, diarrhea (nature / amount) -red, yellow, green, tarry, fatty, mucus, etc), - hemorrhoids, bleeding, pain upon elimination, tenesmus - elimination aids: ____________________________ - melena / occult bld _________ - ostomy, appliances: - incontinent: (Hx:) - Other: - RISK FACTORS:

Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes:

Interventions (include meds & scientific rationale):

- nature & date of last B.M. _______ bowel continent Other:

Evaluation: (of expected outcomes)

URINARY

Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes: Interventions (include meds & scientific rationale):

- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - urine clear and yellow to amber - odorless - urinary continent - pattern of voiding: - suprapubic area (bladder area) soft, flat - 24 hr I/O prior to day of care: I _____ ml O ____ml - 8 hour I/O prior to your shift: I _____ ml O _____ml Hourly output (if app) - BUN WNL/DATE: __________ - Creatinine WNL/DATE: __________ - U/A WNL __________ Other: _________

- MEDICATION INFLUENCES (-): - urine: dk amber, brown, red, cloudy, sediment, odor - oliguria, dysuria, frequency, urgency, hesitancy, burning, retention, nocturia > 1 X; - bladder distention, palpable, firm, - PVR ________ per bladder scan / cath - 24 hr. I/O disproportionate: + (do the math) - comment on disproportionate I/O: - incontinent: (type/nature/ Hx) briefs damp _________ soaked ______ (# times) - urinary cath draining approx ________ ml/hr - appliances: - BUN/Date: __________ ( ) norm - Creatinine/Date:__________ ( ) norm - U/A /Date: _________

Evaluation: (of expected outcomes)

___________________________________________ _ GENITALIA - SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - Clean, smooth with skin intact - Sexual function WNL (if applicable) - Other

___________________________________________ - RISK FACTORS: - MEDICATION INFLUENCES (-): - lesions, poor hygiene, drainage - Sexual dysfunction OTHER:

____________________________________________________ Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes: Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

NUTRITION/FLUIDS
SELF CARE BEHAVIORS

- RISK FACTORS: - MEDICATION INFLUENCES (-):

Nsg Dx: (additional on backcircle this statement to cue instructor)

MEDICATION INFLUENCES (+): Diet ordered in hospital/ supplements: _____________________________________ % last 3 meals = _________________ calorie count adequate appetite satisfactory, taste discriminatory mastication WNL, swallows without difficulty Ht: ______ Wt: _______ comparison to standard: WNL cultural / religious influences describe if applicable home diet / pattern if appicable: (Summary/analysis) intake of fluids - 1500 cc/24 (min) (total of oral, IV, NG, GT) NG / GT formula & rate: Residuals: Calories delivered _______ Required: _______ electrolytes WNL/Date: __________________ albumin WNL/Date: Other:

- noncompliant diet - % intake inadequate: (degree & why) - calorie count inadequate: (degree & Why) - change in appetite, nausea, vomiting (cause) - difficulty chewing, dysphagia: (s/s) ___________ - recent weight loss / gain: - comparison to standard: - intake of fluids: <1500cc/24 (total of oral, IV, NG, GT) - fluid losses: emesis: nature amount ______ NG decompression: nature ________ amt per 2 hrs. ________ - abnormal lytes/ Date: ______________________ - abnormal albumin/Date: ____________ Other: ( )

Exp. Outcomes:

Interventions (include meds & scientific rationale):

Evaluation: (of expected outcomes)

REST AND SLEEP

- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+):

- RISK FACTORS: - MEDICATION INFLUENCES (-):

Nsg. Dx:

At home:
- reports difficulty falling asleep and maintaining sleep (describe degree of problem & sleep habits) - recent change in sleep pattern: - use of hypnotics, sleep walking, nightmares, hallucinations, darkened color around eyes, puffy eyelids, yawning, flat affect, restless, inattentive, confusion, lack of energy; etc. describe:

Expected Outcomes:

At home:
- sleeps 6-9 hours undisturbed nightly, minimal difficulty falling asleep - reports satisfaction with sleep obtained

Interventions (include meds & scientific rationale):

In hospital:
- reports restful sleep OTHER:

In hospital:
OTHER:

- describe degree of problem / cause:

Evaluation: (of expected outcomes)

13

MUSCULOSKELETAL
- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - size of muscles equal bilaterally - firm, coordinated movement - can lift legs off bed one inch - can turn self in bed / shift weight in chair - grips: equal, strong bilateral - fall risk appraisal Score: - steady gait - full range of motion (ROM) all joints - skeletal structure intact - ability to perform ADLs - sense of touch: present all areas, sensitivity WNL Other:

- RISK FACTORS: - MEDICATION INFLUENCES (-): - weakness (describe degree / location): - cannot turn self in bed / cannot shift weight in chair: - cannot lift (Rt / Lt) leg one inch off bed: - atrophy, hypertrophy, contractures - flaccidity, spasticity, paralysis - grips unequal, weak: - unsteady gait; high risk falls - limited ROM (describe): - bones misaligned, FX, tenderness, joint edema - amputation appliances / assistive devices - paresthesia: - Hypersensitivity:

Nsg Dx: (additional on backcircle this statement to cue instructor)

Exp. Outcomes:

Interventions (include meds & scientific rationale):

-If patient has hx of fall, do a comprehensive fall assessment (how / why did this happen). Include assessment on back of this page and circle SEE BACK to cue instructor.

Evaluation: (of expected outcomes)

SKIN
- SELF CARE BEHAVIORS: - MEDICATION INFLUENCES (+): - color within patient norm - warm, dry - skin turgor immediate recoil - fullness, elasticity - skin intact (all skin including pressure points) - Braden Skin assessment > 17 - heels off-loaded / intact - IV site WNL - wound / incision: no redness, drainage, edema, wellapproximated, staples / sutures intact Other:

- RISK FACTORS: - MEDICATION INFLUENCES (-): - jaundice, flushed, pale, cyanosis cool, clammy, hot, diaphoretic - tenting, rough, dry (location) - rash / excoriation (description / location): - Braden skin assessment =_____________ - pressure ulcer (location, stage, characteristics; draw on back on person figure) wounds/incision (describe):

Nsg Dx: (additional on backcircle this statement to cue instructor) Exp. Outcomes:

Interventions (include meds & scientific rationale):

- drainage: (describe amount, nature) - heels not off-loaded, red? - IV site inflamed, infiltrated Other:

Evaluation: (of expected outcomes)

15

FUNCTIONAL ABILITY: (Summary of hygiene, feeding, ambulation, toileting, dressing) (ANY SELF CARE DEFICITS?)

NSG DX: Self-care Deficit R/T AEB Expected outcomes:

Interventions:

Evaluation: (of expected outcomes)

jbohne fall10

Student Code

17