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Florida Community College of Jacksonville

Nursing Care Plan


(revised 10/09/06)
Student: Dates of care:

Client’s Initials: # Age: Sex: Admit date:


Allergies:

Activity: Documented Code Advance Directives:


Status:
Diet: Recommended Diet for this Disease Process
(include purpose)

Primary Medical Diagnosis:

Other Related/Underlying Medical Problems/Diagnoses:

Surgical or Invasive Procedures and Dates (if applicable)

Explanation of Diagnosis, Surgery, and/or Procedure


(State in own words, site textbook source. Include pathophysiology, textbook clinical manifestations, client signs
and symptoms. For Surgery/Procedure, include description of surgery/procedure and related care. If multiple
diagnoses, explain relationships of diagnoses, i.e. how they affect each other)

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MEDICATIONS
Medication Route/ Classification, Major Side Effects Nursing Implications Evaluation/
Generic Safe Dose Time/ Action, & Effectiveness
and Trade Range/ Frequency Indication for Client
Names
Ordered
Dose
C

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Medication Route/ Classification, Major Side Effects Nursing Implications Evaluation/
Generic Safe Dose Time/ Action, & Effectiveness
and Trade Range/ Frequency Indication for Client
Names
Ordered
Dose
C

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LAB/DIAGNOSTIC TESTS
Lab/Diag Tests Purpose of Test Date and Results Implications for abnormals
(List Normal Admission (what caused it for this patient & your
Values) Most Recent interventions for it)
WBC Determine if an infection is
3.4-10.7 k/ul present.
RBC Monitor RBC count/ to
4.0-5.4 mil/ul determine a health problem
Hgb Monitor hemoglobin in RBC/
12.0-16.0 g/dl assist in diagnosing anemia/
ck body fluid deficit
Hct Monitor volume of RBC in
38-47 blood during debilitating
illness
Platelets To check/monitor platelet
125 count
Glucose To confirm diabetic mellitus;
Fasting: 70-110mg/dL monitor blood glucose levels
Na To monitor sodium level; to
135-145 mEq/L compare Na to electrolytes

K To monitor potassium levels


3.5-5.3mEq/L during health problems; to
detect hypo- or
hyperkalemia
Ca To monitor calcium level or
8.8-10.5 imbalance, excess or deficit

BUN To detect renal disorder or


5-25 mg/dL dehydration; determine renal
function
Creatinine Diagnose renal dysfunction
0.5-1.5mg/dl
PT/INR To monitor anticoagulant
2.0-3.0 INR warfarin therapy
PTT Detects deficiency in clotting
22.9-37.8 factor

Other Labs

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X-rays, CT, MRI, Purpose of Test Date Results Implications
US
12 lead EKG, ABG,
etc
To identify bone structure
X-ray and tissue in the body. Also
detects abnormal size,
structure, and shape of bone
and body tissues.
Examination of the body
CT from many angles utilizing a
scanner analyzed by a
computer.
Non-invasive examination
MRI that uses magnet and radio
waves to produce a picture
of inside the body.
A technique that uses high-
US frequency sound waves to
echo off body organs,
creating a picture
Records the electrical
impulses of the heart by the
EKG means of electrodes and
galvanometer (ECG
machine)

ABG’s are usually ordered to


ABG assess disturbances of acid-
base balance caused by a
respiratory disorder and /or
metabolic disorder.

Nursing Diagnoses (PES Format)

1. ___________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________

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4. ____________________________________________________________________________________________________________

5. ___________________________________________________________________________________________________________

6. ___________________________________________________________________________________________________________

7. ____________________________________________________________________________________________________________

8. ___________________________________________________________________________________________________________

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Nursing Process
Nursing S=Supportive Data Goals/Outcomes Nursing Orders & Scientific Basis Client Responses/
Diagnose for Client Intervent for
s Nursing Centered, ions Action/Ra Evaluation
P=Client Diagnosis Stated in Include at least 5 tionale
Problems You must include: Behavioral specific interventions BE SPECIFIC!
(number Subjective Terms per problem. Asterisk Include source and
in order of Objective with (*) those interventions page number for
priority) Desired you implemented.
each intervention.
E=Pathophysiolog Outcomes
y/ (Must be specific
psychosocial and measurable)

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SYSTEM ASSESSMENT
Circle and describe appropriate responses. If abnormal, describe findings in narrative note.
Vital Signs
GENERAL
Description of physical appearance: (Describe how client looks.)

Ht ________ Wt __________________ BMI_____________(N = 18.5-24.9)


BMI= weight (in pounds) divided by height (in inches)2 x 703
State of nutrition: Underweight____ Overweight____ Obese____
(>30)

PAIN Onset and duration:


Location:
Severity (use 0-10 pain scale):
Precipitating or aggravating factors:
Pain med effective?

NEURO Oriented to: time, person, place Describe disorientation:


MENTAL
Numbness, tingling, vertigo, syncope, headache, tremors,
STATUS
seizures, memory loss, aphasia/verbal behaviors, inattentive,
agitation (describe): Cooperative:
Mood scale: Anxiety scale:
Level of sedation: Responding to internal stimuli?
SKIN or Temperature: _______ oral, axillary, rectal; warm, cool, dry,
WOUND clammy
edema, blanching, cyanosis, pallor, jaundice, hyperemia,
ecchymosis, petechiae, bleeding, cuts, boils, decubiti, drainage,
diaphoresis;
rash, hematoma, nail changes.

Describe hydration status:

Describe hair color, condition & distribution:


Tattoos and piercings with location(s):
Dressings/Wounds/Ulcers/Scars (location and description):

Drains/Drainage (type and location):

EYES Vision loss, artificial eye, glasses, contact lens, excessive tearing,
sty, exophthalmus, cataracts, sclera, ptosis, discharge
(describe)__________ other: _____________________
Color____________; Pupils: size_______, reaction PERRLA
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Vital Signs
GENERAL

NOSE Rhinitis, epistaxis, loss of sense of smell, sneezing, patency,


discharge, irritation, other:
Septum: Mucosa:
EARS Deafness, hearing aid, discharge, tinnitus, other:

THROAT & Bleeding gums, caries, dentures, implants, speech impediment,


MOUTH goiter, throat irritation, lesions; lips, gums, buccal membranes,
halitosis
Describe ability to speak, bite, chew, swallow, taste:
Describe dentition:

NECK Goiter, dysphagia, swollen nodes, tracheostomy, hoarseness,


other:
RESPIRATORY Respirations: rate_____ shallow, irregular, regular,
other:____________ nocturnal dyspnea, dyspnea on exertion,
orthopnea, tracheostomy; unequal chest expansion, URI cough:
dry, wet, productive, nonproductive; hemoptysis,
Lung sounds (include location) Clear ____________, Diminished
__________,
crackles ______________________ wheezes ____________________
Oxygen _____L/min Device: (type)_________ Pulse Ox _________
Incentive spirometer _______mL. Nebulizer _______ MDI_______

CARDIO- BP: ________________________ Pulse Pressure: _________


VASCULAR Heart Rate: apical____________ Rhythm: regular____ irregular___
EKG rhythm if monitored: ___________________________________
Peripheral pulse: Radial______ Pedal______ Pulse deficit _____
Edema: pitting_______ non-pitting_______
Capillary refill_______ extremity temp and color: _________________
Palpitations, thrombophlebitis, venous distention ______________
GASTRO- Nausea, vomiting, dysphagia, anorexia, polydipsia, heartburn,
INTESTINAL ascites, constipation, diarrhea, abdominal distention, flatulence,
tarry stool, mucous stools, hemorrhoids, rectal bleeding, pain,
incontinence, hernia, weight loss/gain
Date last B.M and characteristics:
___________________________________
% of diet eaten: ____________________food intolerance
________________
Bowel sounds, 4 quadrants:
_______________________________________
NG tube_______ G tube_______ J tube_______ Ostomy_______

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Vital Signs
GENERAL

GENTIO- Urine:color_______, clear, cloudy, Foley, suprapubic catheter, CBI,


URINARY dysuria, polyuria, oliguria, hematuria, nocturia, incontinence,
flank pain UTI, albuminuria, glucosuria, dribbling, hesitancy,
frequency, burning,
other:______________________________________________
Intake: previous 24 hrs. _________ During care: PO/Tube
_______IV_______
Output: previous 24 hrs. ________ During
care:urine_________other______
REPRODUC- Discharge: _____________ Infection/STD:_______________
TIVE Penis: discharge, irritation. Prostate: enlargement.
Vagina: discharge, irritation, yeast infection.
Menstrual cycle: regular, irregular, post-menopause,
menorrhagia
Post partum: lochia ___________ fundal height____________
Inspect breasts: symmetry, discharge, scars, nipples________
MUSCULO- Atrophy, joint pain, arthritis, gout, claudication, varicose veins,
SKELETAL paralysis, contractures, deformities, amputations, unsteady gait.
Describe ROM and strength in each extremity (0-5 scale):

Describe activity tolerance and ability to ambulate:

Describe posture:
IV/ IV site(s) and type(s)____________________________
INFUSION Gauge__________
CATHETER Date inserted: __________ Site condition:
ASSESSMEN ___________________________
T
Fluids or Drips infusing: __________________________ Rate:
__________
THERAPEUTIC CPM, walker, crutches, cane, trapeze, prosthesis, wheelchair,
Or scooter, SCDs, TEDs, Heating pad, Ice pack, bed fall monitor,
ASSISTIVE therapeutic bed, wound VACs, epidural catheter, IV controller,
DEVICES PCA pump, cooling/heating blanket,

DOCUMENTATION
Date/Ti
Notes
me

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Vital Signs
GENERAL

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