Patient Assessment And Care Plan

13 Jun Patient Assessment And Care Plan

Nursing Clinical Packet

Patient Assessmentand Care Plan

Instructions to student:

1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly.

PATIENT ASSESSMENT FORM

 

STUDENT NAME:

DATE:

 

 

CLIENT INITIALS:

ROOM #

DOB:

AGE

GENDER:

ADMISSION DATE:

 

CODE STATUS:

ALLERGIES:

MARITAL STATUS:

OCCUPATION   (FORMER):

 

MEDICAL DX:

CHIEF   COMPLAINT:

 

PAST HISTORY   (SURGERY/PROCEDURES) WITH DATES

 

ORDERS

RATIONALE(Why is this ordered   for this client???)

 

EXAMPLE:DIET

2 g Sodium diet with nectar thick liquids only

Sodium is restricted due to edema in the bilateral   lower extremities and nectar thick liquids due to dysphagia from a past   stroke.

 

DIET

 

ACTIVITY

 

I/O

 

VS

 

BGM

 

FOLEY

 

NG

 

PEG/PEJ TUBE

 

WOUND CARE

 

RESPIRATORY TREATMENT

 

TRACHEOSTOMY

 

SUCTIONING

 

CHEST TUBE

 

SPECIAL EQUIPMENT

 

LAB ORDERS

 

OTHER

 

REHAB   SERVICES

ACTIVITY OR   TREATMENT PLAN & SCHEDULE

RATIONALE

 

PHYSICAL THERAPY

 

SPEECH THERAPY

 

OCCUPATIONAL THERAPY

 

 

/ 5 pts

IVs

 

IV   FLUID AND RATE:

SITE   LOCATION AND CONDITION:

 

LAST   DRESSING CHANGE:

LAST   TUBING CHANGE:

 

GAUGE:

REASON   FOR IV ACCESS:

 

DIAGNOSTIC   TESTS:

DATE

RESULTS

REASON FOR   TESTING AND IMPLICATIONS FOR NURSING CARE

 

 

 

 

 

 

LAB TEST

DATE

RESULTS

NORMSREFERENCE   RANGES

IMPLICATIONS FOR NURSING CARE   (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP IMPROVE AN   ABNORMAL RESULT?)

 

 

 

 

 

 

 

 

 

 

 

 

 

GROWTH and DEVELOPMENT:(see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development)

 

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO   HAVIGHUSRT

TASKS OF THIS STAGE:

 

ASSESSMENT OF CLIENT’S SUCESSFUL   ACHIEVEMENT OF TASKS

/ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below.

 

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

Coreg (carvedilol)

3.125 mg – 50 mg BID

Asthma, heart block

 

Pharmacotherapeutic Class

Dosage, Route & Frequency

Adverse Reactions

 

β-adrenergic blocker

6.25 mg p.o. BID

Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

He has a history of hypertension but has been taking   Coreg for 2 years to control his hypertension

BP’s   for past 3 days have been 128/78, 132/72, 138/80

How is this medication   impacting your client??B/P readings, lab results, pain management, etc……..

Do   not discontinue abruptly or before surgery

Caution   with Upper airway dysfunction

Rise   slowly to minimize orthostatic hypotension, check B/P and heart rate prior to   administration

Take   before meals

 

#1 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route & Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

#2 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

#3 Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

#4 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

#5 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

# 6 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

#7 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching

 

 

#8 Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

 

 

Pharmacotherapeutic Class

Dosage, Route and Frequency

Adverse Reactions

 

 

Why this Patient Receives this Med

Effects of the Med on the Client

Nursing Considerations and Teaching