risk of deterioration of the integrity Self-care
General Data, Health History, and Review of Systems
( 10 Points)
Biographical Data:
Chief Complaint:
History of Present Illness (Detailed):
Past Medical/Surgical and Injury History:
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
Spiritual Well-Being:
Family History of Illness:
Immunization History:
Developmental Stage in Life:
Description of Procedures (Surgeries) Performed this Admission:
Review of Systems – brief history of each system and use abbreviated format, not complete sentences
General:
Psychiatric:
Skin, hair, and nails:
Lymph nodes:
HEENT (head, eyes, ears, nose, mouth, throat):
Neck:
Blood:
Breasts:
Cardiovascular:
Respiratory:
GI:
GU:
Musculoskeletal:
Neurologic:
Endocrine:
Section II
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan ) References done in APA Format (5 Points)
Pathophysiology of Disease Process
(Points 10)
Classic Signs and Symptoms of Disease Process
(5 Points)
Section III
Physical Assessment
(15 Points)
Physical Assessment:
Vital Signs (T, P, R, BP, SPO2)
General Appearance
Psychiatric
HEENT
Neck
Breasts and Lymph Nodes
Pulmonary
Cardiovascular
Skin and Nails
Abdomen
Genitourinary
Pelvic and Rectal
Extremities
Musculoskeletal
Neurological (DTR’s, reflex grading, cranial nerve evaluation)
Incisions
Drains
Diet/Nutrition
IVs
Intake and Output
Pain assessment (include reassessment)
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Section IV
Diagnostic Data
(5 Points)
Inlcude pertinent diagnostic tests, including labs, EKG, and X-Rays
Diagnostic Tests
Patient’s value
Normal Range
Inference(why is this patients value abnormal)
Section V
Treatments and Procedures
List all treatment and procedure interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
( 5 Points)
Treatments and Procedures
Day & Times
Rationale
Section VI
Teaching and Health Promotion
( 5 Points)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
Section VII
(5 Points)
List of Nursing Diagnoses (Minimum of 5) Use your assessment of your client’s human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.
Human Needs
Nursing Diagnoses
(Circle Selected Nursing Diagnoses)
Nursing Diagnoses Statements
Oxygenation
Perfusion (Cardiac)Acid Base BalanceVentilationDiffusion
Decreased Cardiac output
Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral Impaired Gas exchange Ineffective airways cleaning Ineffective Respiratory pattern Difficulty maintaining spontaneous ventilation, Respiratory dysfunctional response to Weaning High risk of Asphyxia High risk of Aspiration
Fluid & Electrolytes Balance
Acid Base BalanceMetabolismIntracranial Regulation
Liquids, excess volume Liquids, Volume Deficit Liquids, high risk of volume deficit Body temperature: high risk of impaired Hypothermia Hyperthermia Ineffective Thermoregulation
Elimination
Constipation Subjective Constipation Chronic Constipation Diarrhea Fecal Incontinence Urinary, impaired elimination Urinary incontinence: stress Urinary Incontinence: reflects Urinary Incontinence: emergency Urinary Incontinence: Functional Urinary Incontinence: total Urinary, retention Self-care, deficit: use the potty / toilet
Nutrition
EnergyCellular structure and functionFailure to ThriveMetabolism
Nutrition, altered: excess Nutrition, altered: by default Nutrition, potential alterations: excess Self-care, deficit: feeding Swallowing, impaired Ineffective Breastfeeding interrupted breastfeeding Effective Breastfeeding Infant Feeding ineffective pattern
Sleep
Sleep pattern disturbance
Mobility
Disuse, high risk of syndrome Physical mobility, disorder Peripheral Neurovascular, high risk of dysfunction Activity intolerance Activity, high risk of intolerance
Self-care, deficit: dressing / grooming
Sensation and Cognition
Mood and affectTissue integrity
Sen-so-perceptual alterations (specify) visual auditory, kin esthetic, gustatory, tactile, olfactory.
Tissue, impaired integrity Oral mucous membrane, altered Skin, impaired Cutaneous, high risk of deterioration of the integrity Self-care, deficit: bathing / hygiene
Rest and Comfort
PainStress and CopingFatigue
Coping: ineffective
Anxiety Fear FatigueTransfer, stress syndrome Pain Chronic Pain
Spiritual Integrity
Grief and lossCultural
Spiritual suffering HopelessnessImpotence Bereavement dysfunctional Early Mourning
Affiliation
Love and BelongingSocial Support SystemsSelf-Actualization
Verbal, disorder Social, impaired interaction Social isolation Coping: ineffective
Recreation, deficitRole, impaired performance Parenteral, alteration Parenteral, high risk of disruption Parenteral, role conflict Adaptation disorder Family, alteration processes Role of caregiver, overexertion in The role of caregiver, high risk to overuse in the Defensive coping Denial ineffective Ineffective family coping: disabling Ineffective family coping: engaged
Sexual Integrity
Reproductive HealthSexual RelationshipsSexuality
Sexual dysfunction Sexuality, altered patterns of
Safety
Infection and InflammationImmunitySubstance abuseAbusive environments
Infection, high risk of Dysreflexia Injury, high risk Poisoning, high risk of Trauma, high risk of Protection, impaired engaged Violence, high risk: self-injury, injury to other Self-mutilation, high risk of Post-traumatic response Rape, traumatic syndrome of Violation, trauma syndrome: compound reaction Violation, trauma syndrome: silent reaction
Self-Esteem
Developmental milestones across the lifespanHealth promotion/health beliefsBehaviorsTeaching and learning
Growth and development, altered
Coping familiar development potential
Coping:ineffective Knowledge, deficit (specify) Thought, alteration processes
Health, generating conducts (specify)
Treatment, tracking no (specify) Decisions, conflict in the making (specify)
Therapeutic regimen, ineffective management of (individual) Home, difficulties in maintaining Health, alteration in the maintenance of Body Image, disorder Self-esteem disorder Self-esteem, lack of: chronic Self-esteem, lack of: situational Personal, disorder
Section VIII
Medications
(5 Points)
Medication Sheet
Medication Dose
Brand/
Generic Name
Mechanism of Action/Indication for Use
Contraindication
Adverse Effects/Side Effects
Nursing Implications
Outcomes
Safe Dose
(yes or no)
Why is your client on the drug?
Section IX
Nursing Interventions
(Points 20)
CARE PLAN FOR “ 4 ” (MINIMUM) NURSING DIAGNOSES
Assessment
Findings
Nursing Diagnoses
(Actual & Potential Deficits, Wellness Diagnoses)
Outcomes
Short and Long Term
Interventions/Nursing Systems
(Dependent & Independent)
Rationale
(Why are you performing that intervention?)
Evaluation/Outcome
(What was the actual result?)
The post risk of deterioration of the integrity Self-care
