NURSING CARE PLAN 1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2.All nursing care plans must be typed (Times New Roman, 12 po
NURSING CARE PLAN 1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2.All nursing care plans must be typed (Times New Roman, 12 po
% & (Approximate (Brief (Condition, (Frequency (GDM, (Health (Human) (Note (Time, (Times (all (attach (attached) (if (patient (physical, (students +5mL - / 1 1-27______ 1. 1/17/2010 10% 10. 100 12 12.5 1500 17 2 2, 2. 2.All 20 25mg/min 28_____ 3. 300 4-8 4. 40+ 5 5. 6 6. 66 7. 79 8 8. 8.6 9. 9mL : < A ASSESSMENT Abortions Act) Activities Age Alcohol All Allergies: Anesthesia/Analgesia Appearance: Approximate Aspirin, Assessment Assessment, Assessment: At Attachment B/P BMI BP BSC Behaviors: Biographical Birth Birthplace: Blackboard™ Blood Braden Breakfast CARE COLLEGE COMMUNITY Ca Care Care: Cesarean Chief Chronic Circumference Codeine, Complaint) Complications Considerations: Contact: Coombs Cord County__ Current DOB: DTR Data: Date Delivery Delivery: Demecloclycline Diagnoses: Diagnosis: Diet: Dilaudid Direct Drainage EBL EDC Educational English. Episiotomy Ethnic FORM Facility/Unit_Oncology_BMH___ Factor Fall Family Feeding Foods: Forceps Gender Gender__F__ General Gestational Goal Gravidity HIPAA HISTORY HTN, Hair Head Headache, Health Height High History History: Home Home: Hydromorphine INDIANA IV IV. IVY If Illicit Illnesses Impression: Infant Information Initials Instructions: Instructor Insulin Intact Invasive LMP LOW Laceration Length Levothyroxine Lines Lisinopril Living Location__________________ Martial Medical Medications: Mental Morphine, NS NURSING Nails Nails: Needs: New Nystatin O OF Obstetric Occupation: Ondansetron Only Oxygen PHYSICAL PICC PLAN PRN PRN- PROGRAM Pain Past Patient's Penicillin, Perineum: Physical Please Polyethylene Preterm Primary Privacy Promethazine Promotion Protection Pt QID REGION Randolph Reason Reasons Reg Relationship Rh RhoGAM Risk) Roman, Rotation SVD Saturation Scale Score Score: Secondary Section Seeking Sennosides Serious She Site Skin Skin, Social Special Status Student Substance Sulfa Supplemental Support Systems: TECH TID- TPR Term Tetanus, The There Time Tobacco Transcultural Tubes: Type Vacuum Vessels_____ Walker Weight What Widow__ Work X3. _2L___ _7/29/1930__________ _92____ _98.5 _Caucasian_ _DH___ _Vaseline, __0___ __1-26-2010 __142/77____ __5’5”______ __79__ __High __NA________________________________________________________________ __Ovarian __Rash, ___ ___10___Pain ___182_____ ___19 ___30_______ ___NA________________________________________________________________ ___Past ___Pt__ ____ _____ ______ _______ _______Hyposmality___________________________________________________________________ ________ _________ ___________ ___________Apgar _________________ _________________________ __________________________________ ____________________________________________ _____weeks ___hx __general __less __none____________________________________________________________ __self__________________ a abd. about access action adenoidectomy. administrative against age) ago. all allowed already also amount) an and antecubital antihistamine any appendectomy appendectomy, applicable) application approached appropriate are area arm arthritis, assessment at attached attached. authority, available back background bacteria bad based be been behind beliefs, best blood both brand: bruise bruising. but by cancer, cancer. cap care cataracts cataracts, cause cautious chest cholecystectomy, client clinical colon confused. considerations, constipation constipation.” counter, course course. criteria current daily daily- daily. dates: daughter death depression, describes diabetes dilute disease, displayed dose, drugs due duration, each eat. education etc.) evaluation experienced: experienced:_Na_________________________________________ experienced:__NA________________________________________ extremities facial factory female few findings) five fluid font). for form format) four frequency) from front full fungus fx. gallbladder generic genogram given glycol gr grading granddaughter gray had hair. hand hands has have healing health helps her her. herbal here hernia, hiatal highest hives, home home. hospitalization hurts hx hypothyroidism, hysterectomy, i.e. if in include individual infection. information information. initials instructors) involved is kids. kind known) language last left leg level) line little location, lower lowers mL mandates max may mcg med medication meds method mg migraines, ml must name, nausea no note nursing obstetrical occasional of of: old on one onset): or orientation, origin/Race: others. ovarian over oz page pain past patient patient's per personnel. persons pillow plan plan. plans pm point powder pre-eclampsia, prescription, pressing previous prior privacy. problems/complications problems/complications: professional protect providers psychiatric psychological, purports q q2hr q6hr q8hr qdsync quit raise rate reaction reason received. redness refer refill relatives releases relevant remedies, replacement resection, restriction____Consumption retired_________ right rubric scale- scar school school______________ screening seems set. shared she should signs sitting six skill sliding so some someone sometimes son source space, speaks specifically spiritual spit- stated). statement states status status: stay still student student’s surgeries: surgery swelling, swish tab take taking than that the then these thick. three thyroid thyroidectomy, times. to tonsillectomy, tool/results tools top touch, trade tray treatment) twNURSING two tx type type, typed ulcers, unwilling up upon upper use: used used) uses value verbally visit visits walker warm/dry/intact. was water- what who whom. with words worked worker_ year years yellow yrs – “just
NURSING CARE PLAN
Instructions:
1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2.All nursing care plans must be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course. 3. The grading rubric must be attached – last page of nursing care plan. 4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.
HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.
IVY TECH COMMUNITY COLLEGE OF INDIANA – REGION 6
NURSING PROGRAM
NURSING HISTORY & PHYSICAL ASSESSMENT FORM
Student _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit_Oncology_BMH___ Instructor
Health History
Biographical Data:
Patient's Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________
Birthplace: Randolph County__ Ethnic origin/Race: _Caucasian_ Occupation: previous factory worker_
Work status : retired_________ Educational background __High school______________