nursing care plan sample

--1-- NSGCAREPLAN(Sample):1:1/06

NURSING CARE PLAN SAMPLE DATABASE

Mr. Jose Rodriguez, an 84--year--old client, was admitted to the hospital on 6/20/02 with shortness ofbreath. This retired Hispanic grower, a widower, states that for the past 3--4 weeks he has had increasingfatigue and shortness of breath. He visited his doctor two days ago, and his medication was increased. Hispreferred foods are fresh fruits and vegetables, rice, red beans and tortillas. Mr. Rodriguez lives with one ofhis daughters and her family since experiencing a myocardial infarction in 1988. He has six other children.

He is a Catholic and attends church regularly; however, since his declining health, he has been confined tohis home. He is visited at home weekly by his church pastor and/or representative. He speaks with prideabout his grocery store that he started for his family. He smoked two packs per day x 40 years and quit in1990.

Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure (CHF) with acuteexacerbation. His medical history includes coronary artery disease x 10 years. He had a balloonangioplasty in 2000 and an M.I. in 1988. He is hearing impaired and wears bilateral hearing aids. He wearsglasses and reads without difficulty. This is his third admission for CHF since his diagnosis five years ago.Physician progress notes from 6/22/02 state: Condition improving; c/o decreasing SOB; chest x--rayimproving; serum K+ is 3.3, and weight decreased 8# in past two months.

Admitting history and Moderate respiratory distress; crackles auscultated in left lung basePhysical exam Currently sleeping on 3 pillows at night to ease breathing.6--20--02 Nocturia X4 this past week.

Mild heart murmur; no JVD, peripheral pulses +2;VS: 98.6--88--28, 176/94, Ht. 5’7”, Wt. 154#, Baseline BP 145/90c/o increasing fatigue and severe shortness of breath (SOB)O2 SAT level -- 90% on room air. Denies chest pain.

Medications ordered 6--20--02 Digoxin 0.25 mg po QD6--20--02 Lasix 40 mg po bid6--20--02 Nitro--Bid 2.5 mg po qid6--20--02 Metamucil 15 ml po q hs in glass of water/juice6--20--02 KCl 20 mEq po bid

Diagnostic tests results 6/22/02 Chest x--ray--mild left ventricular hypertrophy; pulmonarycongestion resolving.

6/20/02 Serum electrolytes:Na+ 138 mEq/LK+ 3.3 mEq/LCa+ 9.1 mg/dlCL-- 102 mEq/L

6/20/02 Serum albumin 2.8 g/dl6/20/02 Serum digoxin level 2.6 ng/dl6/20/02 Bun 30 mg/dl

Cr 0.6 mg/dl

Other admitting orders No added salt diet; I & O, daily wts, activity as toleratedBRP with assist, VS Q 4 hoursO2 at 3L/min per nasal cannulaHeparin lock

Nursing Interview & States “my old heart is just wearing out. I get this extra fluid every nowObservations and then. I come here to the hospital to get rid of it.” Seems well oriented

and is a fluent historian; accurately reported meds he had been on at home.c/o constipation. Skin reddened over bony prominences. Currentlyrequires HOB elevated to ease breathing. Requires W/C for transport.Needs ADL assist. Gait unsteady. Family at bedside.

--2-- NSGCARE PLAN(Sample):2:1/06

SAMPLE NURSING CARE PLANRIVERSIDE COMMUNITY COLLEGE DATENURSING EDUCATIONSTUDENT________________________________ SEMESTERINSTRUCTOR____________________________ ROTATION

Client’s Initials J.R. Gender M Age 84 Code Status Full Admission Date 6--20--02

Presenting Signs/Symptoms (What brought the client to the hospital?)Increasing fatigue and SOB x 3--4 weeks

Admitting/Primary DiagnosisChronic CHF with acute exacerbation

Surgeries Related to this AdmissionNone

Secondary Diagnoses (Diagnoses other than admitting diagnosis that impact this admission.)CAD (coronary artery disease). S/P MI (1988)

History of Present Illness (What led up to this hospitalization?)Client became more SOB and tired 3--4 weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented toE.R. with ↑ SOB and dyspnea.

Previous Surgical Procedure(s) / Date(s)Balloon Angioplasty (1 vessel) 2000

Health History (Include length of time client has had disease processes; significant family history; social issues.)CAD x 10 years. CHF x 5 years. MI 1988.

Substance Use (Include use of tobacco, alcohol, street drugs, over--the--counter drugs, length of use and time of last use.)2 PPD x 40 years. Quit 1990. Denies ETOH, drug use.

Allergies/Reactions NKA

Religious Preference Catholic Ethnicity Hispanic Marital Status W Occupation Retired

Pathophysiology/Current Health Problems and Related Functional Changes: Define each primary andsecondary diagnosis and explain the disease process of each. Also include signs and symptoms, riskfactors, treatment options, possible complications, and functional changes that affect activities of dailyliving (ADLs). Source: Smeltzer and Bare, 2000

CHF: Congestive heart failure (CHF) often referred to as cardiac failure, is the inability of the heart to pumpsufficient blood to meet the needs of the tissues for oxygen and nutrients. As with coronary artery disease,incidence increases with age. Common underlying conditions that lead to decreased myocardialcontractility include myocardial dysfunction (especially from coronary atherosclerosis), arterialhypertension and valvular dysfunction (p. 622). Functional changes relate to inadequate tissue perfusion,dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities, oliguria, sodium and fluidretention. Increased pulmonary venous pressure leads to cough, SOB and pulmonary edema. Increasedsystemic venous pressure may result in generalized edema and weight gain (p. 665).

CAD: The most common heart disease in the U.S. is atherosclerosis, which is an abnormal accumulation oflipid, or fatty substances and fibrous tissue in the vessel wall. These substances create blockages or narrowthe vessel in a way that reduces blood flow to the myocardium (p. 594). Functional changes depend on thedegree of narrowing. Angina pectoris is recurrent chest pain that is brought on by physical exertion oremotional stress and relieved by rest or medication (p. 595).


Therapeutic/Multidisciplinary Treatment Plan: (Textbook) Source Smeltzer and Bare, 2000

CHF: Medical: Reduce workload of heart; increase the force and efficiency of myocardialcontraction and eliminate the excessive accumulation of body water by avoiding excess fluid intake;controlling the diet and monitoring diuretic and angiotensin--converting enzyme (ACE) inhibitortherapy (p. 665). Nursing: Administer medications and assess the medication effects. Assesspatient’s: intake and output; weight; lung sounds; vital signs; skin turgor and mucous membranes.Assess patient for JVD, edema and signs/symptoms of fluid overload (p. 668). Nurses performcounseling and education concerning regular exercise, sodium restriction, and avoidance ofexcessive fluid intake, alcohol and smoking (p. 668). Pharmacist: Review of medications used fortreatment of CHF including ACE inhibitors, diuretic therapy, digitalis. Monitoring blood levels suchas digoxin (in collaboration with MD and nursing) (p. 666). Registered dietitian: Nutritionassessment and counseling regarding sodium restriction, avoidance of excessive fluid intake andalcohol (p. 668). Respiratory therapist: Administer oxygen therapy based on the degree ofpulmonary congestion and resulting hypoxia. Some patients may need supplemental oxygen therapyduring activity. Others may require hospitalization and endotracheal intubation (p. 666).

CAD: Prevention of CAD by controlling these risk factors is important: high cholesterol, cigarettesmoking, hypertension and diabetes mellitus (p. 595). If CAD is associated with angina, medicalmanagement with drugs and control of risk factors is implemented to decrease the oxygen demandsof the myocardium and to increase the oxygen supply (p. 598). Revascularization procedures includecoronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty(PTCA, also known as balloon angioplasty) (p. 598). Medications include: Ntg, Beta blockers,calcium channel blockers, antiplatelet and anticoagulants (pp. 598--599).

Prescribed Treatments (as per physician’s orders)

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Respiratory Treatment: N/A

IV Infusion: Heparin lock

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-6- NSGCAREPLAN(Sample):6-7:1/06

ADMISSION DATE 6/20/02 ADULT LABORATORY/ DIAGNOSTIC TOOL SOURCE: Nurse’s Manual of Lab Tests (Watson & Jaffe) Test Range Adm.

Result Date/ Result

Date/ Result

Identify ↑ ↓ WNL Significance/ Trends

WBC

5,000-10,000/ mm3

RBCs

4.2-6.1 x 106/µg

Hgb

11.5-17.5 g/dl

Hct

40-52%

MCV

90-95 mm3

MCH

27-31 µg

MCHC

32-36 g/dl

RDW

11%-14.5%

Retic.

0.5%-3.1%

Platelet

150,000- 400,000 mm3

Neutrophils

55-70%

Lymphocytes

20-40%

Monocytes

2-8%

Eosinophils

1-4%

Basophils

0.5-1.0%

Sodium

135-145 mEq/L 138 WNL – most abundant cation in ECF. Normal fluid status. (p. 275)

Chloride

98-106 mEq/L

102 WNL – most abundant anion in ECF. Normal fluid status. (p. 278)

Potassium

3.5-5.0 mEq/L

3.3 ↓ Hypokalemia secondary to Lasix (diuretic therapy). (p. 276)

CO2

24-30 mEq/L

Magnesium

1.3-2.1 mEq/L

Calcium

9.0-10.5 mg/dl

9.1 WNL – Reflects overall calcium metabolism and indicates normal regulation of calcium.

INR

See lab result

PT

11-12.5 seconds

PTT On anticoag. →

60-70 seconds 1.5-2.5 x control

BUN

10-20 mg/dl 30 ↑ Evaluates kidney function. Reduced renal blood flow, no renal damage. Possible protein catabolism.

Creatinine

0.5-1.2 mg/dl 0.6 WNL – evaluates kidney function. No renal damage. (p. 162)

C B C

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L y t e s

C o a g

R e n a l

Note: Normal value range will vary depending on laboratory used.


Test Range Adm. Result

Date/ Result

Date/ Result


Glucose

70-110 mg/dl

Hgb A1c 4.4-6.4%

AST

0-35 U/L

ALT

4-36 IU/L

Acid Phosphatase

0.13-0.63 U/L

Ammonia

80-110 µg/dl

LDH

100-190 U/L

Amylase

30-220 U/L

Lipase

0-160 U/L

Phosphorus

3-4.5 mg/dl

Alk. Phos.

30-120 U/L

Total Bilirubin

.3-1.0 mg/dl

Cholesterol

<200 mg/dl

Uric acid

2.7-8.5 mg/dl

Total protein

6.4-8.3 g/dl

Albumin

3.5-5.0 g/dl 2.8 ↓ Evaluates protein deficiency, hemodilution, ↓ protein in diet, malnutrition (p. 157)

Globulin

2.3-3.4 g/dl

Digoxin level

0.8- 2.0 ng/ml 2.6 ↑ Possible early digoxin toxicity. (p. 992)

Theophylline level

10-20 µg/ml

Dilantin level

10-20 µg/ml

Urinalysis Diagnostic Tests ABGS Date/Result Date/Results Date/Results Date/Results Color X-rays CXR 6-22 mild pH pH Appearance Left Ventricular pCO2 pCO2 Spec. gravity Hypertrophy pO2 PO2 Protein Nuclear scans Pulmonary B.E B.E. Glucose Congestion O2 sat O2 sat Ketones CT/MRI Resolving Comments ___________________________ Bacteria_________________________ _____________________________ Blood________________________ Other _____________________________ Other_________________________________________________________________________________________ Note: Normal value range will vary depending on laboratory used.

B l o o d C h e m.


ADMISSION DATE _________ LABORATORY/ DIAGNOSTIC TOOL SOURCE:______________________ Test Range Adm.

Result Date/ Result

Date/ Result


→

Admitted 6/20/02 SOBIncreasing fatigue SOB x

3--4 weeksO2 3 LPM n/cMI 1988Smoked 2 PPD x 40 yrs.Quit 1990CHF with acute exacerba-tionCAD x 10 yrs.Balloon angioplasty 2000Mod. resp. distressCrackles L lung baseElevate HOBSleeps 3 pillowsMild heart murmurBP 176/94 VS Q 4 hrs.O2 sat 90%6/22 CXR -- mild L

ventricular hypertrophy;pulm congesting resolvingDig level ↑ 2.6DigoxinLasix; Nitro--Bid

Nocturia x 4 past weekI & Oc/o ConstipationMetamucil

Prefers fruits/vegs, rice,red beans, tortillas

K+ 3.3. KCLWt. ↓ 8 poundsNa+ 138K+ 3.3Ca+ 9.1Cl-- 102Albumin 2.8 ↓NAS dietDaily WtsH.L.

Medical Diagnoses:

Hearing impairedBilat H.A.s.GlassesReads with no diff.Skin reddened over

bony prominencesGait unsteady

Oriented x 4AlertFluent historian

Confined to home 3--4 weeksThird admission CHF

Retired Hispanic growerWidowerLives with daughterSix childrenCatholic, attends church regularlyFamily at bedside

Activity as toleratedBRP with assistanceW/C for transportAssist ADL

Denies chest painWidower

NSGCAREPLAN(Sample):10:1/06--10--

CONCEPT MAP

Developmental Stage Very Old Age Psycho--Social Crisis Immortality vs. Extinction

Health--Illness Continuum: Maximum Health Health Illness Death

Oxygen Needs/Circulation Elimination Nutrition/Hydration

1. Chronic CHF with acuteexacerbation.

2. CAD

Problem List/Nursing DiagnosisPrioritize according to Maslow’s Hierarchy1. Impaired gas exchange.

2. Decreased cardiac output.Safety/Skin/Wounds/

3. Nutrition, imbalanced, Drains/Infections/less than body requirements. Sensory

4. Perceived constipation.

5. Impaired physical mobility.

Neurological/Neurovascular AnxietyConcerns/FearKnowledge Needs

Love/Belonging/Culture Rest/Activity Comfort/SexualityCoping/Body Image

-11- NSGCAREPLAN(Sample):11:1/06

NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK Oxygen Needs/Circulation Breathing Airway Clearance, Ineffective Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk for Sudden Infant Death Syndrome, Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional Circulation Cardiac Output, Decreased Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Excess Fluid Volume, Risk for Deficit Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) Neurological/Neurovascular Neurological Confusion, Acute Confusion, Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed Neurovascular Dysreflexia, Autonomic Dysreflexia, Risk for Autonomic Peripheral Neurovascular Dysfunction, Risk for Nutrition/Hydration Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Failure to Thrive, Adult Fluid Volume, Deficit Fluid Volume, Deficit, Risk for Infant Feeding Pattern, Ineffective Nausea Nutrition: Imbalanced, Risk for More Than Body Requirements Nutrition: Imbalanced, Less Than Body Requirements Nutrition: Imbalanced, More Than Body Requirements Nutrition: Readiness for Enhanced Oral Mucous Membranes, Impaired Self-Care Deficit, Feeding Swallowing, Impaired Elimination Bowel Constipation Constipation, Perceived Constipation, Risk for Diarrhea Incontinence, Bowel Nausea Urinary Fluid Volume, Risk for Imbalanced Infection, Risk for Incontinence, Functional Incontinence, Reflex Incontinence, Risk for Urge Incontinence, Stress Incontinence, Total Incontinence, Urge

Tissue Perfusion, Ineffective Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention

Rest/Activity Activity Intolerance Activity Intolerance, Risk for Disuse Syndrome, Risk for Diversional Activity Deficient Fatigue Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Perioperative Positioning Injury, Risk for Sedentary Lifestyle Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for Enhanced Transfer Ability, Impaired Walking, Impaired Comfort/Sexuality Comfort Pain, Acute Pain, Chronic Sexuality Sexuality Pattern, Ineffective Sexual Dysfunction Safety/Skins/Wounds/Infections/Sensory Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced Body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Skin Integrity, Impaired Skin Integrity, Impaired, Risk for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for Disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for Self-Care Deficit, Bathing/Hygiene Self-Care Deficit, Dressing/Grooming Self-Care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field, Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Poisoning, Risk for Self-Mutilation Self-Mutilation, Risk for Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for Other-Directed Violence, Risk for Self-Directed Love/Belonging/Culture/Coping/Body Image Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective

Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for Anxiety Concerns/Fear/Knowledge Needs Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced


Section 1: Physical Assessment *Include all dates/times of care provided.

GENERAL APPEARANCE DATE/TIME INITIAL ASSESSMENTAdmitted in moderate 6--23--02 0800repiratory distress Condition has stabilized since initialAllergies: NKA assessment in E.R.

Date/Time*Explanation ofAbnormalAssessment Factors

Related Nursing Diagnoses(Circle appropriatediagnoses)

Thin, Obese, Emaciated, Well--developed, Well--nourished, No Acute Distress (NAD)Height 5’7” Weight 154 lbs. BMI 24Admitting Vital Signs 98.6 -- 88--28 176/94

Latex Allergy ResponseLatex Allergy Respoonse,

Risk for

I. PHYSIOLOGIC ASSESSMENT

A. OXYGENATION

1. BREATHING Moderate resp.di 3

Airway Clearance, Ineffective

Respiratory Rate 28 Rhythm: -Regular =IrregularDepth: -Deep =Shallow

-No distress -Dyspneic -Apneic ___ sec.=Labored -Accessory muscle use -Tachypneic

R L L R BREATH SOUNDSCl -- ClearCr -- CracklesWh -- WheezingD -- DecreasedA -- Absent

Anterior Posterior

Cl

Cl

Cl

ClClCr

Cl Cl

pdistress, uses 3pillows at night, c/o↑ fatigue & SOB,crackles L base

y ,Aspiration, Risk forBreathing Pattern, IneffectiveGas Exchange, ImpairedInfection, Risk forSuffocation, Risk forVentilation, Impaired,

SpontaneousVentilatory Weaning

Response, Dysfunctional

Oxygen Therapy:-RA =FiO2 3 L / or % =NC -Mask -Trach -Other

O2 Saturation: -N/A =q 8 hr -Continuous pulse oximeterPulse Oximetry Readings (Identify on R.A. or O2): 90RA ; ______; ______

Chest Config: =Symmetrical -Asymmetrical -Flail

Cough: -No cough -Weak -Strong -Frequent =Infrequent=Nonproductive -Productive Description:

Color _______ Odor ________ Viscosity ________ -Incentive Spirometer

Shape of Chest: AP diameter 1:2, barrel, pectus excavatum,(circle) pectus carinatum, kyphotic

Drainage: Chest Tube/Pleuravac: -R -L -Water seal onlySuction ____ cm of water =N/A

Medications R/T Breathing: -Yes =No Type

2. CIRCULATION Weak radial &d li d l

Cardiac Output, Decreased

Heart Rate 88 Rhythm RegularHeart Sounds: Describe S1, S2, Mild heart murmurNeck Veins (45o angle): =Flat -DistendedBP: 176/94 R L Apical Pulse: 88

dorsalis pedalpulses bilat. caprefill prolonged.Bilat ankle edema --pitting 2+ BP

p ,Fluid Balance, Readiness for

EnhancedFluid Volume DeficitFluid Volume Deficit, Risk forFluid Volume Excess

ArterialPulsesRight/Left

C B R PT DP D -- DopplerA -- Absent1+ -- Barely Palpable2+ -- Weak3+ -- Normal4+ -- Full Bounding

F

3+ 3+ 3+ 3+ 2+ 3+ 3+ 3+ 3+2+ 2+ 2+

pitting 2+ BP176/94Baseline 145/90

Fluid Volume ExcessFluid Volume, Risk for

ImbalancedTissue Perfusion, Ineffective

(specify: renal, cerebral,cardiopulmonary,gastrointestinal, peripheral)

Capillary Refill: -Brisk <3 sec. =Prolonged >3 sec. _________ sec.Nail bed Color: =Pink -Pale -Cyanotic

gastrointestinal, peripheral)

Chest Pain: =No -Yes Describe

Edema: Location Bilat. Ankle-None -Generalized -Non--pitting =Pitting 1 + 2 + 3 + 4 + (circle)-Other

Pacemaker: =N/A -Permanent Type-External Rate_____Location:


2. CIRCULATION (Continued) Date/TimeExplanation ofAbnormalAssessment Factors


Homan’s sign: Left: -pos. =neg. Right: -pos. =neg.Calf redness/tenderness: Left: -yes =no Right: -yes =no

Anti--embolism stockings: =N/A -Remove/Replaced q shiftSequential compression device: =N/A -Remove/Replaced q shift-Other

IV’s / INVASIVE LINE MONITORING

Type/Port Solution Rate Dosage Location SiteID** CodeHeparin Lock R wrist C

Digoxin .25 qdNit Bid 2 5*SITE CODE: **ID

C -- Clear INFUSION c -- controllerS -- Swelling DEVICE: p -- pumpR -- Redness pca+ -- PCAI -- Inflamed g -- gravityDI -- Dsg Dry & Intact

Nitro--Bid 2.5Lasix 40 BIDKCl 20 mEq BID

Digoxin level 2.6 --hold digoxin andnotify M.D.

Medications R/T Circulation: =Yes -No Type See abovenotify M.D.

3. NEUROLOGICAL Confusion, AcuteC f i Ch iLevel Of Consciousness:

=Awake =Alert =Oriented x 4 (time, place, person, event)-Restless -Drowsy -Sedated -Confused

,Confusion, ChronicEnvironmental Interpretation

Syndrome, ImpairedInfant Behavior, Disorganized

Glasgow Coma Scale: (Circle number that applies.)a) Best eye opening: 4 Spontaneously 3 To Speech 2 To Pain 1 None

Infant Behavior, DisorganizedInfant Behavior, Readiness for

Enhanced OrganizedInfant Behavior, Risk for

b) Best verbal response: 5 Oriented 4 Confused3 Inappropriate words 2 Incomprehensible sounds 1 None

Infant Behavior, Risk forDisorganized

Intracranial, Decreased AdaptiveCapacity

c) Best motor response: 6 Obeys commands 5 Localizes to pain4 Withdraws 3 Flexion (decorticate)2 Extension (decerebrate) 1 None

CapacityMemory, ImpairedThought Processes, Disturbed

Total Glasgow Coma Scale 15 / 15 (Add a, b, c above)

=PERRL -Pinpoint -Fixed-Dilated, but reactive to light -Dilated, nonreactiveUnequal: -R>L -L>R -Dolls eyes -Other

Brain Stem Signs:(+/--) X N/A ____ cough ____ gag ____ corneal ____ Babinski

Sensation: Location all extremities=Intact -Numbness -Absent -Tingling

Communication: =Verbal -Writes notes -Mouths words-Nods head appropriately to yes/no questions

Medications R/T Neurological Condition: -Yes -No Type

4. NEUROVASCULAR Dysreflexia, AutonomicD fl i Ri k fExtremities Examined: CSM q ___ hr

Traction/Cast: =N/A TypeColor: -Pink -Reddened -Blue -BlanchedTemperature: -Cool -Warm -HotMovement: -Active -Passive -LimitedSensation: -Numbness -Tingling -PainRestraints: =N/A Type CSM q ___ hr-Restraint Protocol Instituted -Remove/Replaced q shift

y ,Dysreflexia, Risk for

AutonomicPeripheral Neurovascular

Dysfunction, Risk for


B. NUTRITION Date/TimeExplanation ofAbnormalAssessment Factors


Abdomen: =Soft -Firm -Hard -Tender -Distended _____cm. Serum albumin↓ 2 8

Breastfeeding, EffectiveBreastfeeding Ineffective

Bowel Sounds: =Active -Hyper -Hypo -AbsentFlatus: =Yes -No

↓ 2.8Wt loss 8 lbs. in2 months

Breastfeeding, IneffectiveBreastfeeding, InterruptedDentition, ImpairedFailure to Thrive, Adult

Diet: Type NAS -NPO -TPN -Tube feedingMeal: =Breakfast -Lunch -Dinner % taken 90%___Type gastric tube =N/A -Placement VerifiedPurpose: -Feeding -Decompression -OtherFormula: Type Rate cc’s q ___ hrs =N/ASuction: =N/A -Intermittent -Low continuousDrainage: Describe

2 monthsLack of appetitieand nauseaRetired grocer,Hispanic, lives withdaughterPrefers fruit/veg,rice, red beans,tortillas

Failure to Thrive, AdultFluid Volume, DeficitFluid Volume, Deficit, Risk forInfant Feeding Pattern,

IneffectiveNauseaNutrition: Imbalanced, Risk for

More Than BodyRequirements

Nutrition: Imbalanced, LessThan Body Requirements

Mucous Membranes: =Moist -Dry -Cracked -Sores -Patches=Pink -Dusky - Other

tortillasConsider dietaryconsult

Than Body RequirementsNutrition: Imbalanced, More

Than Body RequirementsNutrition: Readiness for

Dentures: -Full -Upper -Lower =N/ANutrition: Readiness for

EnhancedOral Mucous Membranes

Diet toleration: =Anorexia =Nausea -Vomiting=Weight Loss: Amount 8 lbs. Time Period 2 mos. -N/A24o Intake 1500 24o Output 1800 on 6/25 Balance: -Positive =Negative/300 ccBlood Glucose Monitoring q ___ hrs Time/Result _____________ =N/A=Self--feed -Assist--feed -Swallowing precautions

Oral Mucous Membranes,Impaired

Self--Care Deficit, FeedingSwallowing, Impaired

Medications R/T Nutrition: -Yes -No Type

C. ELIMINATION ConstipationConstipation Perceived

1. BOWELConstipation, PerceivedConstipation, Risk forDi hStool: =Formed -Loose -Impacted Last BM 6--22

Color: Brown -Regular -Irregular

p ,DiarrheaIncontinence, BowelNausea

Outlet: =Rectum -Colostomy -Ileostomy -Rectal Tube -Fistula

Output: Tube Drainage ______ cc’s Describe:

Stoma: =N/A -Pink -Edema -DuskySurrounding Skin: -D/I -Excoriated -Other

Toileting: =Self -Assist History Laxative Use: -No =Yes

Medications R/T Bowel: =Yes -No Type Metamucil

2. URINARY Nocturia x 4 pastk

Fluid Volume, Risk forImbalanced

GU Drainage: =Voiding -Straight Catheter q ___ hrs-Indwelling Foley -3--way cath (irrigation)-External cath -Other

Other: -Bladder Training -Catheter Care -Hourly Urine OutputBladder Irrigation: -Continuous -Manual Solution:

pweekBUN 30 mg/dlCr 0.6 mg/dlDaily wts.

ImbalancedInfection, Risk forIncontinence, FunctionalIncontinence, ReflexIncontinence, Risk for UrgeIncontinence, StressIncontinence, TotalIncontinence Urge

Urine: =Clear -Cloudy -Sediment Odor: -Faint -OffensiveColor: =Light Yellow -Dark Yellow -Orange -Clots -HematuriaPatterns:-Incontinent -Polyuria =Nocturia -Oliguria -Urgency-Dysuria -Retention -Anuria -Other

Incontinence, UrgeTissue Perfusion, IneffectiveUrinary Elimination, ImpairedUrinary Elimination, Readiness

for EnhancedUrinary Retention

Genitalia: =No Anomalies -Discharge -Excoriation -Other

Medications R/T Bladder: =Yes -No Type Lasix

D. ACTIVITY/REST Requires 3 pillowsat night to sleep

Activity IntoleranceActivity Intolerance, Risk for

Range of Motion: =Active -Passive -LimitationsBed Mobility: =Self Assist: -Partial -Total

at night to sleepc/o difficultysleeping in hospital

Activity Intolerance, Risk forDisuse Syndrome, Risk forDiversional Activity DeficientFatigueM bili I i d B dAssistive Devices: Type =N/A

CPM: -Right -Left =N/A

p g p at gueMobility, Impaired BedMobility, Impaired PhysicalMobility, Impaired WheelchairPerioperative Positioning

Joints: -Tenderness -Pain -Swelling =No abnormalitiesOrdered Activity level: Activity as ToleratedSleep Patterns: Usual # Hours 8 # Last 24 hours 4Special Needs: 3 pillows

Perioperative PositioningInjury, Risk for

Sedentary LifestyleSleep DeprivationSleep Pattern, DisturbedSleep Readiness for EnhancedTransfer Ability Impaired

Medications R/T Activity/Rest: -Yes =No TypeTransfer Ability, ImpairedWalking, Impaired


E. COMFORT Date/TimeExplanation ofAbnormalAssessment Factors


Pain/Discomfort: Describe: denies chest or other painPain Scale: (0--10) ∅ Last Medicated: N/ALocation:Quality:-PRN Analgesic/Narcotic -PCA -EpiduralOther Modalities:

ComfortPain, AcutePain, ChronicSexualSexuality Pattern, IneffectiveSexual DysfunctionSafety and Security

Medications R/T Comfort: =Yes -No Type Nitro--BidSafety and SecurityTemperatureHyperthermia

F. SEXUALHyperthermiaHypothermia

Reproductive: LMP _____ -Premenopausal -Postmenopausal =MaleHysterectomy: =N/A -Ovaries Removed - Ovary/Ovaries RemainBreasts: =Symmetrical -Asymmetrical Describe:Self Breast/Testicle Exams: -Yes =No Freq: __________Cancer Screen: Date 2001 Test PSA Result WNLDate _______ Test ________ Result ________ (Breast, Pap, Prostate, Colon)Sexual/Fertility Concerns: None expressed; Widower-Hormone Replacement

HypothermiaTemperature, Risk for

Imbalanced BodyThermoregulation, IneffectiveSkinInfection, Risk forInjury, Risk forLatex Allergy ResponseLatex Allergy Response,

Risk forP t ti I ff tiMedications Related to Sexuality: -Yes =No Type Protection, IneffectiveSkin Integrity, Impaired

II. SAFETY AND SECURITY Reddened coccyxSkin Integrity, ImpairedSkin Integrity, Impaired,

Ri k fTemperature: 98.6 Route Taken: =Oral -Tympanic -Ax. -Rectal and both heels Risk forTissue Integrity, Impaired

Skin: Turgor: Location: Sternum =Elastic -Tented -Taut -ShinyTemp: -Hot =Warm -Cool -Dry

-Clammy -DiaphoreticColor: Location: __________ =Pink -Pale -Cyanotic

-Flushed -Jaundiced -Mottled -OtherBony Prominences: -Skin Intact =Reddened -Gray

-Pressure Sore Stage: _____ Location: _______________

Tissue Integrity, ImpairedPhysicalFalls, Risk forGrowth, Risk for

DisproportionalMobility, Impaired PhysicalPerioperative Positioning

Injury, Risk forTrauma, Risk for

Wound Location:Wound: =N/A -Sutures -Staples -Drain -Dehiscence

-Evisceration -Healing by secondary intention -OtherDressing: =N/A -Dry/Intact -Open to Air -Stained -SaturatedChanged: q ___ hrs -Wet to Dry -Other Describe:

au a, s oSelf--Care Deficit, Bathing/

HygieneSelf--Care Deficit, Dressing/

GroomingSelf--Care Deficit, ToiletingSurgical Recovery, Delayed

Isolation/Precautions: -Transmission Based Precautions -AdditionalProtocols: =Braden Scale -Restraints -Special Bed -Other

Surgical Recovery, DelayedWanderingPerceptionEnergy Field Disturbed

Physical:General -Unassisted -Supervised =Assisted -UnableMovement: -Hemiparesis/plegia -Paraparesis/plegia

-Quadriparesis/plegia

Energy Field DisturbedEnvironmental Interpretation

Syndrome, ImpairedInfant Behavior, DisorganizedInfant Behavior, Disorganized,

Risk forBathing/Hygiene: -Self =Assist -Total =Partial -PM CareOral Care: -Self =Assist

Risk forInfant Behavior, Readiness for

Enhanced OrganizedPoisonin Risk forAssistive Devices: Type =N/A

Weight Bearing Status: =FWB -L PWB -R PWB -NWB

Poisoning, Risk forSelf--MutilationSelf--Mutilation, Risk for

Precautions: -Swallowing -Seizure -Spinal -Fall -SubarachnoidSelf Mutilation, Risk forSensory/Perception,

Disturbed (specify):Perception:Vision Deficits: -Blind (legally) =Glasses -ContactsHearing Deficits: -Deaf -HOH =Hearing Aid(s): -L -R =Bilat.Other:

Disturbed (specify):Visual, Kinesthetic,Auditory, Gustatory,Tactile, Olfactory

Suicide, Risk forUnilateral Neglect

Precautions: -Danger to Self -Danger to Others -Self Mutilation-Suicide -Alcohol and Drug Withdrawal

Unilateral NeglectViolence, Risk for Other--

DirectedVi l Ri k f S lf Di dMedications R/T Safety and Security: - Yes = No Type Violence, Risk for Self--Directed

NSGCAREPLAN(Sample):16--17:1/06--16--

Section 2: Psychosocial Assessment

Note: It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by observing verbal andnonverbal behaviors and making inferences as you and the patient work toward accomplishing goals and objectives.

III. LOVE AND BELONGING Related Nursing Diagnoses1. Emotional State

a. What seems to be the client’s mood? =Normal for Age/Culture-Withdrawn -Depressed -Anxious -Fearful -Uncooperative-Flat Affect -Elevated -Euphoric -Expressive -Other

2. Client’s Life Experiencea. How have previous life experiences affected the client’s perception of the

current health problems?

“My old heart is wearing out. I get this fluid every now and then. I come

here to the hospital to get rid of it.” Third admission for CHF.

b. How has life changed as a result of the current health problem?

Mr. R has been confined to his home 3--4 weeks. He needs assistance in

ADLs.

c. Describe any signs or symptoms that may indicate actual/potentialphysical/emotional abuse.

No indication of physical/emotional abuse.

3. Familya. What is the client and family’s perception of the illness/admission?

“I’ve had a good life. I just want to be comfortable.” Close Hispanic

family -- 6 children.

b. What evidence indicates that family life has changed?

Mr. R. lives with one of his daughters and her family.

c. How do family members seem to be coping? Ongoing presence of family

members at bedside. No indications of ineffective coping currently.

d. What supportive behaviors from family/significant others are evident?

Visits, concern, supportive family

4. Erikson/Newman/Newman Developmental Stage: Very Old Age

a. What tasks are appropriate for this stage of development?

Immortality vs. Extinction

b. How has this health problem interfered with accomplishing thedevelopment tasks for this client?

Communicates confidence. Although his illness has interfered with his

ADLs, he is coping with the physical changes of aging.

c. What evidence indicates negative or positive developmental resolution?

Talks with pride over his life’s accomplishments. Voices acceptance

of his condition.

Adjustment, ImpairedCaregiver Role StrainCaregiver Role Strain, Risk forCommunication, Impaired VerbalCommunication, Readiness for

EnhancedCommunity Coping, IneffectiveCommunity Coping, Readiness

for EnhancedDelayed Development, Risk forFamily Coping: Compromised,

IneffectiveFamily Coping: DisabledFamily Coping: Readiness

for EnhancedFamily Processes, Dysfunctional:

AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for

EnhancedGrowth and Development, DelayedLoneliness, Risk forParental Role ConflictParent/Infant/Child Attachment,

Impaired, Risk forParenting, ImpairedParenting, Impaired, Risk forParenting, Readiness for EnhancedRole Performance, IneffectiveSocial Interaction, ImpairedSocial IsolationViolence, Risk for

NSGCAREPLAN(Sample):16--17:1/06--17--

IV. SELF--ESTEEM: Related Nursing Diagnoses1. Self--Esteem and Body Image

a. How is the client’s self--esteem threatened by this illness/admission?

Loss of independence can threaten self--esteem.

b. What is the client’s perception of body image and how has it changed?

“I’m glad I’m able to do what I can.”

c. What fears/concerns were expressed by the client that relate to client’spresent illness?

Self--EsteemAdjustment, ImpairedAnxietyBody Image DisturbedCoping, DefensiveCoping, IneffectiveCoping, Readiness for EnhancedDeath AnxietyDecisional Conflict (Specify)Denial, IneffectiveFear

Concern regarding his condition causing “stress” to his daughter and

her family.

2. Culturea. What is the client’s ethnic background? Hispanic

b. How does culture/language influence communication betweenclient/family and healthcare workers?

Hispanic culture has strong family support.

FearGrieving, AnticipatoryGrieving, DysfunctionalGrieving, Dysfunctional, Risk forHopelessnessPersonal Identity, DisturbedPost--Trauma SyndromePost--Trauma Syndrome, Risk forPowerlessnessPowerlessness, Risk forRape--Trauma SyndromeHispanic culture has strong family support.

c. Which communication factors are relevant and why do you think so?(Touch, personal space, eye contact, facial expressions, body language)

Family is demonstrative in affection toward each other.

d. Who seems to be making the healthcare decisions in the family?

Mr. R’s eldest daughter is the surrogate decision maker.

e. Based on your observations, what role does each family member play?

p yRape--Trauma Syndrome, Compound

ReactionRape--Trauma Syndrome, Silent

ReactionReligiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forSelf--Esteem, Chronic LowSelf--Esteem Situational Low

Oldest daughter is “in charge” of others.

f. Who is responsible for care of a sick family member at home?

Eldest daughter.

g. What cultural practices related to hospitalization need to be considered?

Allow time/room for visitors.

3. Spiritualitya What spiritual/religious beliefs does the client express?

Self--Esteem, Situational LowSelf--Esteem, Situational Low,

Risk forSelf--MutilationSelf--Mutilation, Risk forSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well--Being,

Readiness for EnhancedSelf--Actualization

a. What spiritual/religious beliefs does the client express?

Mr. R. is Catholic and attends church.

b. What signs and symptoms if present indicate spiritual distress?

None.

c. What spiritual practices related to hospitalization need to be considered?

Allow/encourage visits from congregation members/priest.

Health Maintenance, IneffectiveHealth Seeking Behaviors (Specify)Home Maintenance, ImpairedKnowledge, Deficient (Specify)Knowledge, Readiness for Enhanced

(Specify)NoncomplianceTherapeutic Regimen: Community,

Ineffective Management ofTherapeutic Regimen: Families,

Ineffective Management ofV. SELF--ACTUALIZATION

Ineffective Management ofTherapeutic Regimen: Management,

1. What is the client’s/family’s current level of understanding of theirhealth/illness problem?

Accepts condition and understands the diagnosis.2. What type of relationship exists with healthcare providers?

Cooperative, respectful.

Education/discharge planning: See M.E.T.H.O.D. attached.

Therapeutic Regimen: Management,Effective

Therapeutic Regimen: Management,Ineffective

Therapeutic Regimen: Management,Readiness for Enhanced


SAMPLE CARE PLAN FORM

The following pages are an example of how to write a care plan using the

accepted format for RCC. This is not a complete care plan related to JR’s

problems, but rather a brief example to show proper use of the format.

RCC Nursing Education Programs Nursing Care Plan

Student Name: Jane Doe ID: 11111 Course: N17 Date: 2/16/02

Client Initials: JR Admission date: 2/02/02 Age: 84 Gender: M Medical Diagnosis: Congestive Heart Failure


Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) – Collaborative (Circle)

Rationale & APA Reference (Use various sources)

Evaluation of Interventions

NDX: (Problem) Cardiac output, decreased R/T: (etiology/factor) (not the medical diagnosis): Altered myocardial contractility AEB: (s/sx; defining characteristics) (Identify all that apply) 1. Dyspnea: c/o shortness of breath with mild exertion. 2. Blood pressure, increased: 176/94 3. Rales in left base of lung *If ‘risk for’ identify what the client would exhibit (note there are no signs and symptoms for ‘risk for’ problems):

Goal: (Reversal of problem) Adequate cardiac output Client will (list measurable outcomes; reverse signs and symptoms) 1. Demonstrate no dyspnea within 24 hrs 2. BP returns to baseline of 145/80 within 24 hrs 3. Lungs clear to auscultation by time of discharge Evaluation of Outcomes (address each outcome) 1.Dyspnea decreased but still present with exertion 2. BP still elevated (154/96) 3.Rales diminished but still present

ASSESS: (May have less or more than 4) N1-(I) Assess general appearance for weakness, fatigue, edema q shift and prn N2-(I) Assess lungs sounds q 4 hrs N3- (I) Count apical pulse rate q 4 hrs N4- (I) Count respiratory rate q 4 hrs N5- (I) Measure BP q 4 hours N6- (I) Assess peripheral pulses q 4 hrs

R1- These s/s develop as the heart attempts to compensate for a decreased C.O. with resultant decrease in O2 supply to body’s tissues (Smeltzer & Bare, 1996, p. 581-2). R2- Fluid accumulation in lungs may occur with decreased C.O. (Carpenito, 2000, p. 14) R3- With decreased C.O. peripheral pulses may be weakened & pulse count may be inaccurate at peripheral sites (Smeltzer & Bare, 1996, p. 582). R4- Assessment of respiratory rate can reveal symptoms r/t fluid overload (Sparks & Taylor, 2004, p. 59). R5- To ascertain response to therapy-increased BP is a sign of stress on the system (Smeltzer & Bare, p. 582) R6- Peripheral circulation maybe be impaired with decreased C.O. (Smeltzer & Bare, p. 582)

E1- Denies fatigue/weakness at present. No edema noted. E2- Rales decreased but present in L base. R lung clear. E3- Apical pulse 78 bpm E4- RR 14-18 E5- BP 154/96; decreased from 176/94 E6- Radial and dorsalis pedal pulses 2+, others 3+








Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care

ACTIVITIES: (May have less or more than 4) N1- (I) Elevate head of bed 15-45 degrees. Use cardiac chair when OOB N2- (I) Assist as needed with ambulation and with shower N3- (I) Measure and document intake & output q 4 hrs & prn. N4- (I) (C)

R1- These anatomical positions facilitate ease of breathing & promote rest (Smeltzer & Bare, 2000, p. 583) R2- Client may tire easily or become dyspneic-need to conserve energy (Smeltzer & Bare, 2000, p. 621) R3- Accurate I & O is essential for monitoring for potential fluid overload (Sparks & Taylor, 2004, p. 42) R4-

E1- Positions self with HOB elevated 15 degress. Sat in chair X30 min twice during day. E2- Ambulated to BR without respiratory distress. Partial bed bath given instead of shower. E3- Intake 400cc this shift, output 850cc. E4-








MEDICATIONS: (May have less or more than 4) N1- (I) Give Nitro Bid 2.5 mg po QD as ordered @0900 after checking Digoxin level N2- (I) Give Lasix 40 mg p.o. BID after checking K+ level.

R1- SEE TACTIS on medication sheet R2- SEE TACTIS on medication sheet

Evaluate TACTIS of each Medication. E1- Med held. Digoxin level 2.6. M.D. called. E2- T – BP remains elevated 154/96; No edema noted. A – Na+ and Cl- reabsorption inhibited. C – No hypersensitivity or other contraindications noted. T – K+ 3.3 K-rider given I – Assess for dehydration – No S/S. S – 40 mg safe dose (20-80 mg/day safe).








TEACHING: (May have less or more than 4) N1- (I) (C) Teach patient about medications and activity restrictions N2- (I) (C) N3- (I) (C) N4- (I) (C)

May use “See Method” only if you include the teaching point on the Method. R1- See METHOD R2- R3- R4-

May use “See Method” only if you include the teaching point on the Method. E1- See METHOD E2- E3- E4-


M.E.T.H.O.D. Daily Teaching Plan and Evaluation

PATIENT INITIALS: J.R. LEARNERS PRESENT (circle): Client X Family Sig.Other Other Daughter MEDICAL DIAGNOSES: CHF; CAD TECHNIQUES: Discussion Q/A Demos Handout(s) Other ______________

Date Complete & Initials

Content

Evaluation

06/23/02 JD

M (Medications): Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset. Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.

M = Discussed each medication. Knew the purpose of each drug. Was checking his own blood pressure each week at home, using cuff he bought at the drugstore. Needs to review side effects and precautions of both lasix and digoxin. Given written patient drug information.

06/23/02 JD

E (Environment): Your eldest daughter will provide help with activities of daily living in the home. She will transport you to follow-up appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allows you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.

E = He lives with his eldest daughter who helps him with meals, medication administration, getting to appointments, etc. Verbalizes understanding of fall prevention and activity level. Understands appointment date and time for follow-up.


06/23/02 JD

T (Treatments): Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)

T = Daughter was able to demonstrate proper positioning. Client and daughter able to describe skin care.

6/23/02 JD

H (Health knowledge of disease): Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.

H = Verbalizes signs and symptoms of electrolyte imbalance and digoxin toxicity. He stated what foods are high in potassium and what foods to avoid that are high in sodium. Demonstrated how to assess pulse rate and when to call the doctor.

6/23/02 JD

O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.

O = Given information for national and regional resources related to heart disease. Referrals to VNA, dietician and Meals on wheels completed.

6/23/02 JD

D: (Diet): Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.

D = Diet teaching completed regarding low salt, high potassium diet. F/U with dietician as outpatient arranged. Client and daughter state they understand diet. . Meals on wheels contacted.

Schuster, P. (2000). The key to the therapeutic relationship. Philadelphia: FA Davis. Schuster, P. (2002). Concept Mapping: A critical thinking approach to care planning. Philadelphia:

FA Davis.

-25- NSGCAREPLAN(Sample):25:1/06

Directions for Using METHOD Daily Teaching Plan General Guidelines 1. Write the instructions for the client. These are not guidelines for the nurse who will be doing the teaching. 2. Complete all sections, recognizing that each section may not be taught in one session. 3. Complete one METHOD per client. 4. In the Evaluation column, either describe the client response to the teaching or indicate the reason the

teaching did not take place. 5. The content must be stated in simple, specific terms, so the client can understand the instructions. 6. Assessment forms the basis for teaching in each area, and is therefore always the first step. 7. Use learning principles when preparing the teaching plan. This would include such things as selecting the

right time for the teaching and building on the client’s prior knowledge of the subject. Medications 1. First assess the client’s knowledge about their medications and address any newly prescribed or unfamiliar

medications. 2. Give specific S/S of expected and adverse effects, timing of medications and interactions. 3. Include web addresses for accessing information about medications (as indicated). Ex. www.nlm.nih.gov/medlineplus (National Institute of Health) www.safemedication.com/about/factsheet.html (American Society of Health System Pharmacists) www.fdagov/cder/consumerinfo/default.html (Federal Drug Administration: for newest drug information) Environment 1. Definition: Factors that affect the client’s health care in the facility or home. 2. Examples

a. safety b. activity order, including restrictions c. availability of transportation d. psychosocial issues e. finances f. cleanliness

3. Directions a. Identify pertinent environmental factors assessed by the nurse. b. Describe teaching needed to help the client modify the environment.

Treatments 1. If the client is in a facility: Teach the purpose of the treatment(s) and how the client can assist when the

treatment(s) is/are performed. 2. If the client is at home: Provide simple directions about how to perform the procedure, including

technique, safety measures, and supplies/equipment needed. Health Knowledge of Disease 1. Assess the client’s knowledge about the disease and provide information essential for managing the

condition. 2. Provide web sites for obtaining information about the disease. 3. Teach S/S of complications. Examples

a. wound: S/S infection b. heart: S/S of heart failure

4. Teach when to contact the primary healthcare provider and how to do that. Outpatient/Inpatient Referrals: Instructions are included on the form. Diet 1. Include purpose and cultural adaptations. 2. Consider finances and who will be shopping for and preparing the food.

nursing care plan sample

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