Nursing Care Plan Data Base

NURSING CARE PLAN DATA BASE

Date Submitted: _____________________Name of Student: _______________________

Clients Initials: _____ Age: _____ Date of Client Care: ______________________

Language Spoken: __________________Date Admitted: _______

Rm. # _______

Diagnoses: _ _______________________Brief explanation of diagnoses:______________________________________________________________________________________________________________________________________________

Pertinent Past History: _________________________________________________________________Surgical Procedure: ___________________________Date: ______________________________

Oxygen Order (specify): _____________________ Patient behaviors from developmental

assessment:Developmental stage according to Erickson:

_________________________________________1. ___________________________________List 3 appropriate tasks.

2. ___________________________________1. _______________________________________3. ___________________________________2. _______________________________________Has your patient met the appropriate

developmental task?3. _______________________________________

YES [ ]NO [ ]Baseline Vitals:

Current Vitals:

(0900)

(1200)

T _____

T _____

P _____

P _____

R _____

R _____

B/P _____

B/P _____Mental Status: (check)

[ ] Alert

[ ] Confused

[ ] Oriented

[ ] Comatose

[ ] Stupor

Elimination Status: (describe)

Bladder: _____________________ __________________________________________

Bowel: ____________________ ____________________________________________

Normal RangePatient ValueExplain Deviation

Hgbg/dL

Hct%

FBGMg/dl

WBCK/L

RBCmil/L

NamEq/L

K+mEq/L

CreatininemEq/dL

BUNmEq/dL

pH

PO2mmHg

PCO2mmHg

HCO3mEq/L

Appointments: _______________________________________

_______________________________________

Other significant tests / procedures:

______________________________________________________________________________________________________________________________________________________________________________________________

OTHER:

Nursing Diagnoses / Client Problem

Nursing Approach

Diet Order: __________ Restrictions:__________ I.V. Order: ______________________________

Mode if Intake: (check) Drop Factor: _____ gtts/ml rate: _________

[ ] p.o. [ ] ng tube [ ] gastrostomy tube [ ] TPN Amount LIB at 9 a.m. ________________

Appetite: _______________________________ Amount LIB at 12 noon ______________

YESNO

Physical care required:

[ ] complete [ ] assisted [ ] self

Activity status:

[ ] bed rest [ ] BRP [ ] OOB

Safety devices:

[ ] side rails [ ] restraints

[ ] other (specify) _ ______________________

Position restrictions: _____________________Intake & OutputFoley CatheterTexas CatheterFinger stick (BG)Respiratory Therapy (R.T.)Physical Therapy (P.T.)Occupational Therapy (O.T.)DressingIrrigations

M E D I C A T I O N SMedicationClassif.DoseFreqRoute