Client Care Plan Form

Client Care Plan Form - Client Care Plan Client initials:...

Info iconThis preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: Client Care Plan Client initials:       Sex:       Age:       Student:       Date:       Code status:       Cultural influences:       Diagnosis:       Surgery:       History of Present Illness (HPI) Past Medical History (PMH)             Definitions, Abbreviations, Etiology/Risk Factors Client Etiology/Client Risk Factors             Pathophysiology       Clinical Manifestations Client Symptoms             Expected Diagnostic Evaluation       NS V40 Client Care Plan 1 Rev. 8/2005 Air Data Gathering/Diagnostic Tests PT       INR       PTT       ABGs: pH       pCO2       pO2       HCO3       O2 Sat.       Base Excess       Drug Serum Level:       EKG:       C & S Sputum:       X-ray:       CBC: WBC       RBC       Hgb       HCT       MCV       MCH       MCHC       Retic.       Sed. Rate       Platelets       INTEGUMENTARY (color, temperature, moisture, oral mucosa, turgor, lesions, pruritus, dressings, wounds, incisions, drainage, erythema, IV site) RESPIRATORY (rate, rhythm, lung sounds, SOB, O2, cyanosis, TCBD, spirometer, tracheotomy, cough, sputum appearance) CARDIAC (apical pulse rate & rhythm, blood pressure) VASCULAR (venous distention, quality of peripheral pulses, edema, calf tenderness, capillary refill, paresthesia, pain) Narrative Assessment Pathophysiology NANDAs             Differential: PMS (Segs & Neutrophils)       Lymphs       Monocytes       Eosinophils       Basophils       Bands       CPK-MB       Airway clearance, ineffective Aspiration, risk for Breathing pattern, ineffective Gas exchange, impaired Suffocation, risk for Skin integrity, impaired Skin integrity, impaired risk Cardiac output, decreased Tissue perfusion,       altered Dysreflexia Knowledge deficit R/T       Non-compliance Pain, acute/chronic Troponin       BNP       NS V40 Client Care Plan 2 Rev. 8/2005 Digestive Data Gathering/Diagnostic Tests T. Protein       Albumin       Prealbumin       Globulin       A/G Ratio       Liver Test: ALP       ALT       AST       GGT       LDH       Amylase       Bilirubin       Ammonia       Lipids: CHOL       TRIG       HDL       LDL       VLDL       PKU       X-rays:       Glucose       FSGB       Serum Iron       Ferritin       TIBC       Renal Test: BUN       Creat.       Uric Acid       Electrolytes: Na+       K+       Cl       CO2       Ca       Phos.       Mg       Urinalysis: Spec. Gr.       pH       Protein       Glucose       WBC       RBC       Bacteria       Mucous Threads       Crystals       Stool: Occult blood       O & P       NS V40 Client Care Plan FOOD/WATER (Diet type, percent eaten, tolerance, IV, swallowing, weight gain or loss) ELIMINATION (Genitourinary: color, amount, voiding pattern, catheter, dialysis, drainage tubes, odor, penile or vaginal discharge, 24 hour I & O) GASTROINTESTINAL (Bowel sounds, abdomenal distention, palpation, last BM, frequency, pattern, ostomy, nausea, vomiting, flatus, drainage tubes) Narrative Assessment Pathophysiology NANDAs             3 Fluid volume deficit Fluid volume deficit, risk for Fluid volume, excess Nutrition, altered: less/greater than body requirement Oral mucosa membrane Swallowing, impaired Infant feeding pattern, ineffective Breast feeding       Incontinence, type       Urinary elimination, altered pattern Urinary retention Self-care deficit: toileting Bowel incontinence Constipation Constipation: perceived/colonic Diarrhea Pain, acute/chronic Knowledge deficit R/T       Non-compliance Rev. 8/2005 Normalcy PSYCHOSOCIAL (Behavior, emotions, anxiety, depression, anger, thought disturbance, judgment, insight into illness) Data Gathering/Diagnostic Tests       Narrative Assessment Pathophysiology       Activity/Rest Data Gathering/Diagnostic Tests Serum drug levels:       X-rays:       EEG:       NS V40 Client Care Plan                   NANDAs Anxiety Ineffective patient/family coping Powerlessness Spiritual distress Grieving Body image disturbance Social isolation Confusion, acute/chronic Knowledge deficit R/T       Non-compliance MUSCULOSKELETAL (Activity level, ADL, gait, assistive devices, extremity movement, CMS of involved extremity, PAIN (Location, quality, scale 1-10) SLEEP (Pattern, remedies) NEUROLOGICAL (LOC, orientation, PERRL, memory, numbness, tingling, tremors, Glasgow Coma Scale, sensation) Narrative Assessment Pathophysiology NANDAs 4 Fatigue Activity intolerance Mobility, impaired Diversional activity deficit Peripheral neurovascular dysfunction Sleep disturbance Thought process, altered Disuse syndrome Memory, impaired Confusion, acute/chronic Infant behavior       Knowledge deficit R/T       Non-compliance       Pain, acute/chronic Rev. 8/2005 Solitude and Social Interaction Data Gathering/Diagnostic Tests       Special senses exam, discomfort, communication, sexuality, menses, vaginal drainage (lochia), breast, fundus of uterus, history of pregnancy Social skills, coping skills assets and strengths, communication content and speech pattern Narrative Assessment Pathophysiology NANDAs       Hazards Data Gathering/Diagnostic Tests Blood alcohol:       Drug levels:       Developmental SCR Data Gathering/Diagnostic Tests Erickson’s Stage:       Describe DSCR task:       NS V40 Client Care Plan       SUBSTANCE ABUSE (Specify level of use) SAFETY (Restraints) Narrative Assessment Thought process, altered Sensory perceptual alteration Impaired verbal communication Sexual dysfunction Knowledge deficit R/T       Non-compliance       Pathophysiology             (Maturational/Situational, Physical & Cognitive)             NANDAs Ineffective individual coping Ineffective family coping Risk for self-mutilation Non-compliance Knowledge deficit R/T       Developmental tasks, adjustments related to aging, parenting behaviors, experiences that impact human development, grieving process Weight (pounds/kilograms and percentile), length/height (inches & percentile), head circumference (inches & percentile) Narrative Assessment Pathophysiology NANDAs 5 Growth & development, delayed Parenting, altered, potential for Coping, family, altered/ineffective Conflict, parental Role performance, altered Knowledge deficit R/T       Situational low self-esteem Rev. 8/2005 NS V40 – Part A Nursing System: No. 1 Prioritized Nursing Diagnosis Assessment Identify which self-care requisite you are working on: USCR, DSCR, HDSCR       Client Goals, Desired Outcomes, Time Frame       Nursing Responsibilities       Rationale       Evaluation Effectiveness of Nursing Interventions:       Goal Accomplished? Check one: Yes Partially No Suggested Revisions:       NS V40 Client Care Plan 6 Rev. 8/2005 NS V40 – Part A Nursing System: No. 2 Prioritized Nursing Diagnosis Assessment Identify which self-care requisite you are working on: USCR, DSCR, HDSCR       Client Goals, Desired Outcomes, Time Frame       Nursing Responsibilities       Rationale       Evaluation Effectiveness of Nursing Interventions:       Goal Accomplished? Check one: Yes Partially No Suggested Revisions:       NS V40 Client Care Plan 7 Rev. 8/2005 NS V40 – Part A Nursing System: No. 3 Prioritized Nursing Diagnosis Assessment Identify which self-care requisite you are working on: USCR, DSCR, HDSCR       Client Goals, Desired Outcomes, Time Frame       Nursing Responsibilities       Rationale       Evaluation Effectiveness of Nursing Interventions:       Goal Accomplished? Check one: Yes Partially No Suggested Revisions:       NS V40 Client Care Plan 8 Rev. 8/2005 ...
View Full Document

Ask a homework question - tutors are online