NCP Nursing Nursing Care Plan Form - Majmaah...

1 Dr. Eyad Naji 2013

NCP Nursing Care Plan Form

Date: Student Name:

Clinical Instructor: Clinical Area:

(5%) Nursing Admission Data Base

Client: X Age: Sex:

Ward: Room No.: Bed No.:

Spoken Language:

Date of Admission: Via:

Source of Data:

Condition on arrival: Walking Wheelchair Stretcher (0.5 Mark)

(0.5 Mark) Reasons for Hospitalization:

(1 Mark) Confirmed Diagnosis:

(1 Mark) Medication taken at home:

A: Prescribed: No

Yes (specify

B: Non– Prescribed: No

Yes (specify)

Past medical history: (1 Mark)

Past surgical history: (0.75 Mark)

Family history: (0.75 Mark)

Department of

Nursing



(15%) Assessment (Subjective Data)

1. Health Maintenance Perception Pattern. (2 Marks)

A: Smoking: No

Yes: No. of Cigarettes/ day.

Quit (Date)

B: Alcohol: No

Yes (amount)

C: Allergies (drugs, food, tape, dyes, dust, insects): No

Yes (specify)

2. Nutrition Metabolic pattern (3 Mark)

A: Diet: Typical diet at home:

Prescribe diet:

B: Appetite: Normal

Increased

Decreased

C: Nausea: No

Yes

D: Vomiting: No

Yes (describe)

F: Dysphagia: No

Yes

G: Weight changes within last 6 months: No

Yes

Kg gained/ lost:

H: Dentures: Upper

Lower

Partial

Department of

Nursing



3. Activity Exercise pattern (2 Mark)

Self care ability: (Use codes: 1 = independent, 2 = needs Assistance, 3 = dependent).

Activity 1 2 3

Feeding

Bathing

Dressing/Grooming

Toiling

Mobility

Assistive devices : No

: Yes (specify)

4. Elimination Pattern (4 Mark)

A: Bowel habits:

Number of bowel movements/day

Last bowel movement

Constipation

Diarrhea

Distention

Incontinence

Bleeding

Painful defecation

Ostomy

Assistive devices: No

Yes (Specify)

B: Urinary Habits: Frequency

(times/day)

Color

Dysuria

Oliguria

Urgency

Hematuria

Anuria

Nocturia (times/ night)

Retention

Burning

Assistive devices: No

Yes (specify)

Department of

Nursing



5. Sleep Rest Pattern (1.5 Mark)

A: Usual number of hours/ night:

AM naps:

PM naps:

B: Use of drugs: No

Yes (specify)

C: Any change in habits after hospitalization: No

Yes (specify)

6. Cognitive Conceptual Pattern (3 Mark)

A: Hearing: Impaired (Rt, Lt)

Deaf (Rt, Lt)

Tinnitus

Hearing aids

None

B: Vision: Impaired (Rt, Lt)

Glasses

Contact lenses

Blind (Rt, Lt)

None

C: Vertigo: No

Yes

D: Discomfort/ pain: No

Yes (describe)

7. Coping Stress Self Perception Pattern (1 Mark)

A: Major concerns regarding hospitalization of illness:

B: Major loss/ change: No

Yes (specify)

C: Coping mechanisms:

Department of

Nursing



8. Value /Belief Pattern (1 Mark)

A: Religion:

B: Spiritual Habits:

9. Role Relationship Pattern (1.5 Mark)

A: Occupation:

B: House- ld members: (Specify)

C: Family concerns regarding hospitalization:

10. Sexual Reproductive Pattern (1 Mark)

A: Testicular exam: No

Yes

Physical Examination (Objective Data)

(10%)

1. General Survey (1 Mark)

Level of consciousness:

Orientation:

2. Nutritional Metabolic pattern (4 Mark)

A: Skin:

Color

Symmetrical

Temperature

Turgor

Texture

Moisture

Lesions: No

Yes (describe)

Edema: No

Yes

Pruritus: No

Yes

Tubes: No

Yes (specify)

Department of

Nursing



B: Oral Cavity:

Lips (describe)

Gums (describe)

Teeth (describe)

Tongue (describe)

Mucous membrane & adjacent structures (describe)

C: Neck: Symmetrical: Yes

No (specify)

Thyroid

Carotid pulse

Jugular venous pressure

Lymph node enlargement: No

Yes (describe)

D: Abdomen:

Symmetrical: No

Yes

Contour

Umbilicus

Number of bowel sounds / minute

Abnormal sounds: No

Yes (specify)

Masses: No

Yes (specify)

Organomegally: No

Yes (specify)

Tenderness: No

Yes (specify)

Other data:

Department of

Nursing



3. Activity Exercise Pattern (3 Mark)

A: Lung &Thorax Respiration:

(describe)

Symmetrical chest movements: yes

No (specify)

Lung expansion (describe)

B: Cardiovascular:

Blood pressure

Apical pulse (describe)

Peripheral pulses (describe)

Abnormal heart sounds: No

Yes (describe)

C: Musculoskeletal:

Tempomandibular joint: (describe)

Neck joints: (describe)

Upper extremity joints: (describe)

Lower extremity joints: (describe)

Spine: (describe)

4. Cognitive perceptual Pattern (2 Mark)

A: Eyes:

B: Ears:

C: Nose:

D: Mental status: able to calculate: Yes \ No

Thinking abstractly: Yes \ No

Memory: Yes

No (specify)

E: Neurological status:

Intact cranial nerves: Yes

No (specify)

Intact sensory function: Yes

No (specify)

Intact motor function: Yes

No (specify)

Deep tendon reflexes (draw a picture)

Department of

Nursing



Medication (10%)

Drug's Allergies: No

Yes (Specify)

Drugs and

Classification

(2 Mark)

For this Patient

Action/indication

(1 Mark)

Dose/ Route

Frequency

(3 Mark)

Contra-

Indications

(1 Mark)

Expected

Side effects

(1 Mark)

Nursing Implications

(2 Mark)

Department of

Nursing



Diagnostic Evaluation

(Lab results, X-ray, ECG, procedures) (10%)

Date

Test Performed

(1 Mark)

Normal Value

(2 Mark)

Patient Value

(2 Mark)

Interpretations &

Nursing Implications

(5 Mark)

Department of

Nursing



Nursing Care Plan (40%)

Functional

Health

Pattern

(4 Mark)

Nursing

Diagnosis

(6 Mark)

Evidenced by

/Defining

Characteristics

(6 Mark)

Short-Term

Goals

(6 Mark)

Planned

Intervention

(With Rationale)

(6 Mark)

Actual

Intervention

(6 Mark)

The Outcome

(With Rationale)

(6 Mark)

Department of

Nursing



Discharge Care Plan (10%)

Date &Sign

(0.5 Mark)

Plan and Outcome

(3 Mark)

Target Date:

(0.5 Mark)

Nursing Interventions

(5.5 Mark)

Date Achieved

(0.5 Mark)

Department of

Nursing


Index Key (examples)

Discharge Care Plan (10%)

Date &Sign

(0.5 Mark)

Date &Sign

(0.5 Mark)

Date &Sign

(0.5 Mark)

Date &Sign

(0.5 Mark)

Date &Sign

(0.5 Mark) The patient/family's discharge planning

will begin on day of admission

including preparation for education

and/or equipment.

On the day of discharge, patient/family

will receive verbal and written

instructions concerning:

o Medications

o diet

o Activity

o Treatments

o Follow up appointments

o Signs and symptoms to observe

for (when to contact the doctor)

Care of incisions, wounds, etc.

Other:

Assess needs of patient/family beginning

on the day of admission and continue

assessment during hospitalization.

Anticipated needs/services:

o Respiratory equipment

o Hospital bed

o Wheel char

o Walker

o Home health nurse

o Home PT/OT/ST

Involve the patient/family in the

discharge process.

Discuss with physician the discharge plan

and obtain orders if needed.

Contact appropriate personnel with

orders.

Provide written and verbal instructions at

the patient/family's level of

understanding.

Verbally explain instructions to

patient/family prior to discharge and

provide patient/family with a written

copy.

Ascertain that patient has follow-up care

arranged at discharge.

Provide verbal and written information on

what signs and symptoms to observe and

when to contact the physician.


Assess if any community resources

should be utilized (i.e.: Home Health

Nurse), and contact appropriate

personnel.

Document all discharge teaching on

Discharge Instruction Sheet and Nursing

notes.

Other:________________

________________________

________________________

________________________

The patient/family's discharge planning

will begin on day of admission

including preparation for education

and/or equipment.

On the day of discharge, patient/family

will receive verbal and written

instructions concerning:

o Medications

o diet

o Activity

o Treatments

o Follow up appointments

o Signs and symptoms to observe

for (when to contact the doctor)

Care of incisions, wounds, etc.

Other:

Assess needs of patient/family beginning

on the day of admission and continue

assessment during hospitalization.

Anticipated needs/services:

o Respiratory equipment

o Hospital bed

o Wheel char

o Walker

o Home health nurse

o Home PT/OT/ST

Involve the patient/family in the

discharge process.

Discuss with physician the discharge plan

and obtain orders if needed.

Contact appropriate personnel with

orders.

Provide written and verbal instructions at

the patient/family's level of

understanding.

Verbally explain instructions to

patient/family prior to discharge and

provide patient/family with a written

copy.

Ascertain that patient has follow-up care

arranged at discharge.


Provide verbal and written information on

what signs and symptoms to observe and

when to contact the physician.

Assess if any community resources

should be utilized (i.e.: Home Health

Nurse), and contact appropriate

personnel.

Document all discharge teaching on

Discharge Instruction Sheet and Nursing

notes.

Other:________________

________________________

________________________

________________________


Index Key

(Draw a picture)

+4 = hyperactive

+3 = more than normal

+2 = normal

+1 = low than normal

0 = no response


Index Key

Family history

Female

Dead female

Dead male

Male

House hold

Abortion

The patient


Guidelines for Review of Body Systems

Use the following format for review of body systems to completes all your assignments:

GENERAL:

[ ] Recent weight changes.

[ ] Fever/ chills.

[ ] Malaise/ general weakness.

[ ] Mood changes

SKIN, HAIR, AND NAILS:

[ ] Rashes

[ ] Lesions

[ ] Itching

[ ] Color change

[ ] Dryness

[ ] Brittle nails

[ ] Cracking

[ ] Others

HEAD:

[ ] Headache

[ ] Seizure

[ ] Fainting

[ ] Head injuries

[ ] Dizziness

EYES:

[ ] Changes in vision

[ ] Blindness

[ ] Cataract

[ ] Diplopia

[ ] Redness

[ ] Pain

[ ] Photophobia

[ ] Glasses (last exam date and results)

[ ] Contact lenses (type)

[ ] Glaucoma

[ ] Drainage

[ ] Infection

[ ] others

EARS:

[ ] Difficulty in hearing/ deafness

[ ] Tinnitus

[ ] Vertigo

[ ] Infection

[ ] Discharge

[ ] Others

NOSE AND SINUSES:

[ ] Nasal stuffiness

[ ] Frequent colds

[ ] Hay fever

[ ] Nose bleeds

[ ] Sinus troubles/ infection


MOUTH, PHARYNX, AND NECK:

[ ] Bleeding from gums/ teeth

[ ] Oral infection

[ ] Dental problems

[ ] Dentures (last exam, time and results)

[ ] Hoarseness

[ ] Swelling in neck

[ ] Frequent sore throats

[ ] Lumps in neck

[ ] Dysphagia

[ ] Stiffness in neck

[ ] other

BREASTS:

[ ] Prurutus, pain, lumps

[ ] Nipple discharge

[ ] Dimpling of skin

[ ] Enlargement (gynecosmastia)

[ ] Performance of self breast exam

[ ] Mammograms (date, results)

[ ] Steroids

[ ] others

LUNGS:

[ ] Shortness of breath

[ ] Dyspnea on exertion

[ ] Orthopnea

[ ] Pain with respiration

[ ] Cough

[ ] Sputum (color, frequency, quantity)

[ ] Hemopteysis

[ ] Wheezing

[ ] Cyanosis

[ ] Pneumonia

[ ] Bronchitis

[ ] Emphysema

[ ] Asthma

[ ] TB test ( results and date)

[ ] TB exposure

[ ] Chest X-ray ( date and results)

[ ] others

HEART:

[ ] Heart troubles

[ ] High blood pressure

[ ] Heart murmurs

[ ] Paroxysmal nocturnal dyspnea

[ ] Chest discomfort/ pain

[ ] Palpitations

[ ] Syncope

[ ] Rheumatic fever

[ ] Coronary Artery disease

[ ] Heart attack

[ ] ECG ( results and dates)

[ ] Other heart tests

[ ] Others


PERIPHERAL VASCULAR:

[ ] Edema

[ ] Swelling/ pain calves

[ ] Pain/ ulcerations or discoloration of extremities

[ ] Cramps

[ ] Varicose veins

[ ] Others

GASTROINTESTINAL: [ ] Nausea

[ ] Vomiting

[ ] Hematemesis

[ ] Indigestion/ heart burn

[ ] Abdominal pain

[ ] Jaundice

[ ] Hepatitis

[ ] Melena

[ ] Clay colored stools

[ ] Incontinence of stool

[ ] Diarrhea

[ ] Change in bowel habit

[ ] Constipation

[ ] Hemorrhoids

[ ] Excessive gas

[ ] Hernia

[ ] Ulcer

[ ] Gall bladder stone/ colic

[ ] Pancreatic disease

[ ] Others

URINARY:

[ ] Frequency

[ ] Urgency

[ ] Infection

[ ] Dysuria

[ ] Nocturia

[ ] Hematuria

[ ] Stream site and force

[ ] Hesitancy

[ ] Incontinence (stress, urge, dribbling)

[ ] Others

MALE GENITALIA:

[ ] Discharge

[ ] Genital lesions

[ ] Testicular pain/ mass

[ ] Syphilis positive serology

[ ] Gonorrhea

[ ] Sexual problems

[ ] Others

FEMALE GENITALIA:

[ ] Viginal discharge

[ ] Pruritis

[ ] Genital lesions

[ ] Painful intercourse

[ ] Post menstrual bleeding

[ ] Post coital bleeding

[ ] Pap smear ( results, dates)

[ ] Other


ENDOCRINE:

[ ] Heat and cold intolerance

[ ] Thyroid problems

[ ] Neck Surgery

[ ] Diabetes

HEMATOPOIETIC:

[ ] Abnormal bleeding/ bruising

[ ] Anemia

[ ] Transfusions

[ ] Leukemia

[ ] Blood type

[ ] Others

SPINE AND EXTREMITIES: MUSCOLOSKELETAL

[ ] Arthritis

[ ] Joint stiffness

[ ] Joint swelling

[ ] Joint pain

[ ] Muscle weakness

[ ] Muscle cramps

[ ] Backache

[ ] Limited ROM

[ ] Others

SPINE AND EXTREMITIES: NEUROLOGICAL

[ ] Paresthesia/ numbness

[ ] Paralysis

[ ] Incoordination

[ ] Disturbed balance

[ ] Fainting (LOC)

[ ] Blackouts

[ ] Tics

[ ] Tremors

[ ] Spasms

[ ] Others

PSYCHIATRIC (Problems in the following areas):

[ ] Spouse

[ ] Family

[ ] Peers

[ ] Insomnia

[ ] Depression (interfering with ADL’s)

[ ] Anxiety interfering with ADL’s)

[ ] Mood swings

[ ] Delusions

[ ] Hallucinations

[ ] Eating, sleeping, memory problems

[ ] Others

NCP Nursing Nursing Care Plan Form - Majmaah...

Documents

Transcript of NCP Nursing Nursing Care Plan Form - Majmaah...