Name: Date:
Care Plan #
| Nursing Care Plan: Basic Conditioning Factors | |
| A. Patient identifiers:
Age: Gender: Ht: Wt. Code Status: Isolation: |
Development Stage (Erikson): Give the stage and rationale for your evaluation
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| Health Status | |
| Date of admission:
Activity level: Diet: Fall risk (indicate reason)
Client’s description of health status
Allergies: (include type of reaction)
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Reason for admission:
Past medical history that relates to admission: |
| Socio-cultural Orientation | |
| Cultural and Ethnic Background with current practices:
Socialization:
Family system: (Support system)
Spiritual:
Occupation: (across the lifespan)
Patterns of living: (define past and current)
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| Barriers to independent living:
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| Healthcare systems elements (continued) ALLERGIES: | |||||
| Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.
DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication? Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference |
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Oxytocin |
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Carboprost (Methergine) |
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Hemabate |
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Misoprostol (Cytotec) |
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CON CEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Postpartum Hemorrhage
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
Nursing Diagnosis
Problem statement: (NANDA)
Related to: (What is happening in the body to cause the issue?)
Manifested by: (Specific symptoms)
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| LAB VALUES AND INTERPRETETION
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| LAB | Range | Value | Value | MEANING (If WDL then explain the possible reason for the lab) | LAB | Range | Value | Value | MEANING |
| HEMATOLOGY | CHEMISTRY | ||||||||
| CBC | Glucose | ||||||||
| WBC | BUN | ||||||||
| RBC | Cr | ||||||||
| HGB | GFR | ||||||||
| HCT | Na | ||||||||
| PLATLETS | K | ||||||||
| Diff: | CO2 | ||||||||
| Polys | Ca | ||||||||
| Bands | Phos | ||||||||
| Lymphs | Amlylase | ||||||||
| Mono’s | Lipase | ||||||||
| Eosin | Uric Acid | ||||||||
| GBC indices | Protein | ||||||||
| MCV | Albumin | ||||||||
| MCH | Cl | ||||||||
| MCHC | Enzymes | ||||||||
| COAG’S | LDH | ||||||||
| PT | CPK | ||||||||
| INR | SGOT | ||||||||
| PTT | SGPT | ||||||||
| ABG’S(V 0R A) | Triponin I | ||||||||
| PH | Myoglobin | ||||||||
| PCO2 | |||||||||
| PO2 | Cholesterol | ||||||||
| BASE EX: | UA | ||||||||
| SAT: | |||||||||
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URINALYSIS |
Range |
Value |
Value |
Meaning |
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Findings |
Meaning |
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| Color | Gastroccult | ||||||||
| Clarity | Hemoccult | ||||||||
| Sp. Gravity |
SEROLOGY |
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| pH | HIV | ||||||||
| Protein | GBS | ||||||||
| Glucose | Gonorrhea/ Chlamydia | ||||||||
| Ketones | Syphilis | ||||||||
| Bilirubin | Hepatitis B | ||||||||
| Occ. Blood | Rubella | ||||||||
| Urobilogen | BLOOD TYPE | ||||||||
| WBC | RH FACTOR | ||||||||
| RBC | |||||||||
| Epithelia | RADIOLOGY | ||||||||
| WBC | EKG | ||||||||
| RBC | CT | ||||||||
| Epith Cell | PET SCAN | ||||||||
| Bacteria | MRI | ||||||||
| Hyal Cast | MRA | ||||||||
| Gran Cast | Ultrasounds | ||||||||
| Leukocytes | |||||||||
| Nitrite | |||||||||
| ACCUCHECKS | Endoscopy | ||||||||
| Colonoscopy | |||||||||
| Additional information:
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| Universal Self-Care Deficits: Assessment: (Highlight all abnormal assessment findings) | |||||
| Vital Signs | Admission | Reassess | |||
| Input: | |||||
| Output:
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| Cardiovascular Assessment:
Specialty devices:
Teaching needs: |
Heart Sounds:
Circulatory Assessment:
Edema: |
Pain assessment: (PQRST)- Specific area | |||
| Respiratory assessment
Special devices:
Teaching Needs: |
Lung sounds:
Pulmonary assessment: (respiratory pattern) |
Cough:
Respiratory treatment and rational for use: |
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| Breast assessment:
Teaching Needs: |
Breast Assessment:
Nipple assessment:
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Breastfeeding plans:
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| Uterine Assessment:
Teaching needs: |
Location:
Firmness: |
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| GI Assessment:
Teaching needs:
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GI assessment: (observe – auscultate – palpate)
Alteration in eating or elimination patterns:
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Nutrition Metabolic Assessment:
% of diet taken:
Alternative nutritional methods:
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| GU assessment:
Teaching needs: |
Last void:
Due to void: Alternative urinary elimination method: (if Foley when inserted)
Bladder scan |
Assessment of urinary patterns:
Urine assessment (color odor concentration etc.)
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| Lochia Assessment:
Teaching needs:
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Color:
Quantity:
Presence of clots: |
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| Perineal Assessment:
Teaching needs:
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REEDA:
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Wound Care:
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| Thrombophlebitis Assessment:
Teaching needs:
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| Edema Assessment:
Teaching needs:
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| Emotional Assessment:
Teaching needs:
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Edinburgh Postnatal
Depression Screening: |
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| IV Therapies:
IV fluids infusing
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IV Site 1: Assessment
Date of insertion: Change (site or dressing)
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IV removal: | Reason for removal: | ||
Additional information:
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE: Use your top two priorities
| NANDA NURSING DIAGNOSIS use NANDA definition | Expected outcomes of care (Goals) | Interventions | Patient response | Goal evaluation |
| NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
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Short term goal : Create a SMART goal that relates to hospital stay/shift/day.
Long term goal : Create a SMART goal that is appropriate for discharge.
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This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal: 1. 2. 3.
Interventions for longterm goal: 1. 2. 3.
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Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal: 1. 2. 3.
Reassess for long-term goal: 1. 2. 3.
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Was it met or not met there is no partially met. |
| NANDA NURSING DIAGNOSIS use NANDA definition | Expected outcomes of care (Goals) | Interventions | Patient response | Goal evaluation |
| NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom?)
Manifested by: (specific symptoms)
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Short term goal: Create a SMART goal that relates to hospital stay.
Long term goal: Create a SMART goal that is appropriate for discharge.
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This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
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Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) | Was it met or not met there is no partially met. |
Summer 2021 JM 9
