Nursing Care Plan: Basic Conditioning Factors<\/p>\n
A. Patient identifiers:<\/p>\n
Age: Gender: Ht: Wt. Code Status:<\/p>\n
Isolation:<\/p>\n
Development Stage (Erikson): Give the stage and rationale for your Assessment<\/p>\n
Health Status<\/p>\n
Date of admission:<\/p>\n
Activity level: Diet:<\/p>\n
Fall risk (indicate reason)<\/p>\n
Client\u2019s description of health status<\/p>\n
Allergies: (include type of reaction)<\/p>\n
Reason for admission:<\/p>\n
Past medical history that relates to admission:<\/p>\n
Socio-cultural Orientation<\/p>\n
Cultural and Ethnic Background with current practices:<\/p>\n
Socialization:<\/p>\n
Family system: (Support system)<\/p>\n
Spiritual:<\/p>\n
Occupation: (across the lifespan)<\/p>\n
Patterns of living: (define past and current)<\/p>\n
Barriers to independent living:<\/p>\n
Healthcare systems elements (continued) ALLERGIES:<\/p>\n
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.<\/p>\n
DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?<\/p>\n
Medication\/dose Classification Indication\/ Rationale SE\u2019s\/Nursing Considerations Client Education Text Reference<\/p>\n
Potassium chloride 40 mEq PO<\/p>\n
Ondansetron 4-8 mg slow ush IV q6 hr<\/p>\n
Sultamethoxasole\/trimethoprim 160\/180<\/p>\n
Dextrose 5% NS with 20 mEq KCL<\/p>\n
CON CEPT MAP<\/p>\n
Pathophysiology \u2013 (to the cellular level)<\/p>\n
Medical Diagnosis<\/p>\n
Hypovolemia<\/p>\n
Signs & Symptoms\/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)<\/p>\n
Complications<\/p>\n
Treatment (Medical, medications, intervention and supportive)<\/p>\n
Causes\/Risk Factors (chemical, environmental, psychological, physiological and genetic)<\/p>\n
Nursing Diagnosis<\/p>\n
Problem statement: (NANDA)<\/p>\n
Related to: (What is happening in the body to cause the issue?)<\/p>\n
Manifested by: (Specific symptoms)<\/p>\n
.<\/p>\n
LAB VALUES AND INTERPRETETION<\/p>\n
LAB<\/p>\n
Range<\/p>\n
Value<\/p>\n
Value<\/p>\n
MEANING (If WDL then explain the possible reason for the lab)<\/p>\n
LAB<\/p>\n
Range<\/p>\n
Value<\/p>\n
Value<\/p>\n
MEANING<\/p>\n
HEMATOLOGY<\/p>\n
CHEMISTRY<\/p>\n
CBC<\/p>\n
Glucose<\/p>\n
WBC<\/p>\n
BUN<\/p>\n
RBC<\/p>\n
Cr<\/p>\n
HGB<\/p>\n
GFR<\/p>\n
HCT<\/p>\n
Na<\/p>\n
PLATLETS<\/p>\n
K<\/p>\n
Diff:<\/p>\n
CO2<\/p>\n
Polys<\/p>\n
Ca<\/p>\n
Bands<\/p>\n
Phos<\/p>\n
Lymphs<\/p>\n
Amlylase<\/p>\n
Mono\u2019s<\/p>\n
Lipase<\/p>\n
Eosin<\/p>\n
Uric Acid<\/p>\n
GBC indices<\/p>\n
Protein<\/p>\n
MCV<\/p>\n
Albumin<\/p>\n
MCH<\/p>\n
Cl<\/p>\n
MCHC<\/p>\n
Enzymes<\/p>\n
COAG\u2019S<\/p>\n
LDH<\/p>\n
PT<\/p>\n
CPK<\/p>\n
INR<\/p>\n
SGOT<\/p>\n
PTT<\/p>\n
SGPT<\/p>\n
ABG\u2019S(V 0R A)<\/p>\n
Troponin I<\/p>\n
PH<\/p>\n
Myoglobin<\/p>\n
PCO2<\/p>\n
PO2<\/p>\n
Cholesterol<\/p>\n
HCO3<\/p>\n
UA<\/p>\n
BASE EX:<\/p>\n
Urine osmolality<\/p>\n
URINALYSIS<\/p>\n
Range<\/p>\n
Value<\/p>\n
Value<\/p>\n
Meaning<\/p>\n
Findings<\/p>\n
Meaning<\/p>\n
Color<\/p>\n
Gastroccult<\/p>\n
Clarity<\/p>\n
Hemoccult<\/p>\n
Sp. Gravity<\/p>\n
pH<\/p>\n
Protein<\/p>\n
Glucose<\/p>\n
Ketones<\/p>\n
Bilirubin<\/p>\n
Occ. Blood<\/p>\n
RADIOLOGY<\/p>\n
Urobilogen<\/p>\n
Xray<\/p>\n
WBC<\/p>\n
EKG<\/p>\n
RBC<\/p>\n
Epithelia<\/p>\n
PET SCAN<\/p>\n
WBC<\/p>\n
RBC<\/p>\n
CT<\/p>\n
Epith Cell<\/p>\n
Bacteria<\/p>\n
MRI<\/p>\n
Hyal Cast<\/p>\n
MRA<\/p>\n
Gran Cast<\/p>\n
Ultrasounds<\/p>\n
Leukocytes<\/p>\n
Nitrite<\/p>\n
ACCUCHECKS<\/p>\n
Endoscopy<\/p>\n
Colonoscopy<\/p>\n
Additional information:<\/p>\n
Universal Self-Care Deficits: Assessment: (Highlight all abnormal assessment findings)<\/p>\n
Vital Signs<\/p>\n
Admission<\/p>\n
Reassess<\/p>\n
Oxygenation\/ Circulation<\/p>\n
Input:<\/p>\n
SPO2<\/p>\n
1. 2. 3.<\/p>\n
Accu-check<\/p>\n
1. 2. 3. 4.<\/p>\n
Output:<\/p>\n
Cardiovascular Assessment:<\/p>\n
Specialty devices:<\/p>\n
Teaching needs:<\/p>\n
Heart Sounds:<\/p>\n
Circulatory Assessment:<\/p>\n
Edema: JVD:<\/p>\n
Pain assessment: (PQRST)- Specific area<\/p>\n
Respiratory assessment<\/p>\n
Special devices:<\/p>\n
Teaching Needs:<\/p>\n
Lung sounds:<\/p>\n
Pulmonary assessment: (respiratory pattern)<\/p>\n
Cough:<\/p>\n
Respiratory treatment and rational for use:<\/p>\n
Neurological assessment:<\/p>\n
Helpive devices:<\/p>\n
Teaching Needs:<\/p>\n
Neuro assessment: Level of Consciousness<\/p>\n
Fine motor function:<\/p>\n
Gross motor functioning:<\/p>\n
Sleep patterns: (During admission)<\/p>\n
GI Assessment:<\/p>\n
LBM: (description)<\/p>\n
Teaching needs:<\/p>\n
GI assessment: (observe \u2013 auscultate – palpate)<\/p>\n
Alteration in eating or elimination patterns:<\/p>\n
Nutrition Metabolic Assessment:<\/p>\n
% of diet taken:<\/p>\n
Alternative nutritional methods:<\/p>\n
GU assessment:<\/p>\n
Teaching needs:<\/p>\n
Last void:<\/p>\n
Due to void:<\/p>\n
Alternative urinary elimination method: (if Foley when inserted)<\/p>\n
Bladder scan<\/p>\n
Assessment of urinary patterns:<\/p>\n
Urine assessment (color odor concentration etc.)<\/p>\n
LMP<\/p>\n
Integumentary Assessment:<\/p>\n
Teaching needs:<\/p>\n
Color\/ Mucous membranes<\/p>\n
Hydration:<\/p>\n
Wound Care:<\/p>\n
Condition of skin:<\/p>\n
Nutritional Assessment<\/p>\n
Teaching needs:<\/p>\n
Diet:<\/p>\n
Eating patterns:<\/p>\n
Insulin administration:<\/p>\n
Treatment of hypoglycemia:<\/p>\n
Alternative feeding patterns:<\/p>\n
IV Therapies:<\/p>\n
IV fluids infusing<\/p>\n
IV Site 1: Assessment<\/p>\n
Date of insertion: Change (site or dressing)<\/p>\n
IV removal:<\/p>\n
Reason for removal:<\/p>\n
Additional information:<\/p>\n
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT\u2019S RESPONSE IS SPECIFICALLY HIS RESPONSE.<\/p>\n
PLAN OF CARE: Use your top two priorities<\/p>\n
NANDA NURSING DIAGNOSIS use NANDA definition<\/p>\n
Expected outcomes of care (Goals)<\/p>\n
Interventions<\/p>\n
Patient response<\/p>\n
Goal Assessment<\/p>\n
NRS DX:<\/p>\n
Problem Statement:<\/p>\n
R\/T: (What is the cause of the symptom)<\/p>\n
Manifested by: (Specific symptoms)<\/p>\n
Short term goal : Create a SMART goal that relates to hospital stay\/shift\/day.<\/p>\n
Long term goal : Create a SMART goal that is appropriate for discharge.<\/p>\n
This is specific to the patient that you are caring for. A list of planned actions that will Help the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat\/ likes)<\/p>\n
Interventions for short-term goal:<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Interventions for longterm goal:<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Identify what the patients response or \u201coutcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)<\/p>\n
Reassess for short-term goal:<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Reassess for long-term goal:<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Was it met or not met there is no partially met.<\/p>\n
NANDA NURSING DIAGNOSIS use NANDA definition<\/p>\n
Expected outcomes of care (Goals)<\/p>\n
Interventions<\/p>\n
Patient response<\/p>\n
Goal Assessment<\/p>\n
NRS DX:<\/p>\n
Problem Statement:<\/p>\n
R\/T: (What is the cause of the symptom?)<\/p>\n
Manifested by: (specific symptoms)<\/p>\n
Short term goal: Create a SMART goal that relates to hospital stay.<\/p>\n
Long term goal: Create a SMART goal that is appropriate for discharge.<\/p>\n
This is specific to the patient that you are caring for. A list of planned actions that will Help the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat\/ likes)<\/p>\n
Identify what the patients response or \u201coutcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)<\/p>\n
Was it met or not met there is no partially met.<\/p>\n
Pilot Summer 2016 KC 9<\/p>\n
—–<\/p>\n
Basic Conditioning Factors in Nursing Care<\/p>\n
A. Identifiers for patients:<\/p>\n
Gender: Height: Weight: Code Status:<\/p>\n
Isolation:<\/p>\n
Development Stage (Erikson): Describe the stage and rationale for your assessment.<\/p>\n
Condition of Health<\/p>\n
Date of admission:<\/p>\n
Activity level: Diet:<\/p>\n
Fall risk (indicate reason)<\/p>\n
Client\u2019s description of health status<\/p>\n
Allergies: (include type of reaction)<\/p>\n
Reason for admission:<\/p>\n
Past medical history that relates to admission:<\/p>\n
Socio-cultural Orientation<\/p>\n
Cultural and Ethnic Background with current practices:<\/p>\n
Socialization:<\/p>\n
Family system: (Support system)<\/p>\n
Spiritual:<\/p>\n
Occupation: (across the lifespan)<\/p>\n
Patterns of living: (define past and current)<\/p>\n
Barriers to independent living:<\/p>\n
Healthcare systems elements (continued) ALLERGIES:<\/p>\n
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.<\/p>\n
DEFINE<\/p>\n","protected":false},"excerpt":{"rendered":"
Nursing Care Plan: Basic Conditioning Factors A. Patient identifiers: Age: Gender: Ht: Wt. Code Status: Isolation: Development Stage (Erikson): Give the stage and rationale for\u2026<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8797,8792,8791,8795,8796,8798,8785,8800,8786,8784,8788,8794,8793,8789,8799,8790,8787],"tags":[103,95,83,94,80,86,79,98,93,104,32,99,92,82,102,85,8,101,97,87,96,91,89,90,820,88,100,84,81],"class_list":["post-99133","post","type-post","status-publish","format-standard","hentry","category-assignment-helper","category-assignment-writers","category-assignment-writing-services-near-me","category-best-assignment-writing-service","category-engineering-assignment-writing-service","category-essay-writing-help-free-essay-writer","category-homework-help-free","category-homework-help-global-tiktok-guy","category-homework-help-online","category-homework-help-websites","category-homework-solver","category-homework-writer-free","category-homework-writer-online","category-homework-writing-jobs","category-homework-writing-machine","category-homework-writing-services-online","category-top-homework-helper","tag-150-200-words-discussion-with-a-scholarly-reference","tag-200-300-words-response-to-classmate-discussion-question","tag-250-word-analysis-essay","tag-bachelor-of-nursing-assignments","tag-case-study","tag-essay-bishops-website","tag-expert-online-nursing-writing-service","tag-fast-nursing-papers","tag-freelance-case-study-writing-service","tag-health-medicine-assignment-help-australia","tag-health-care-and-life-sciences-paper-writers","tag-health-care-assignment-help-service","tag-healthcare-assignment-writing-services-by-top-writers","tag-healthcare-essay-writing-services-by-medical-academics","tag-healthcare-writing-help-by-certified-medical-academics","tag-i-need-to-submit-this-assignment","tag-medical-essay-writing-service","tag-nursing-assessment-help","tag-nursing-assignment-help","tag-nursing-assignment-help-australia","tag-nursing-assignment-help-sydney","tag-nursing-assignment-writers","tag-nursing-assignments-examples-assignment-help-nursing","tag-pay-someone-to-do-my-nursing-assignment","tag-professional","tag-professional-case-study-writers","tag-quality-nursing-essay-writing-service","tag-write-a-review","tag-writing-assignment"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/99133","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/comments?post=99133"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/99133\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/media?parent=99133"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/categories?post=99133"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/tags?post=99133"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}