Social Worker

by
                      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 your evaluation

 

 
Health Status  
Date of admission:

Activity level:                                                                Diet:

Fall risk (indicate reason)

 

Client’s description of health status

 

 

 

Allergies: (include type of reaction)

 

 

 

 Reason for admission:

 

 

 

 

 

Past medical history that relates to admission:
Socio-cultural Orientation  
Cultural and Ethnic Background with current practices:

 

Socialization:

 

Family system: (Support system)

 

Spiritual:

 

Occupation: (across the lifespan)

 

Patterns of living: (define past and current)

 
Barriers to independent living:

 

 

 

Healthcare systems elements (continued)                      ALLERGIES:
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.

                                 DEFINE 1:  What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?

Medication/dose              Classification          Indication/ Rationale        SE’s/Nursing Considerations                 Client Education                    Text Reference
 

Oxytocin

          
 

Carboprost (Methergine)

          
 

Hemabate

          
 

Misoprostol (Cytotec)

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          
 

 

          

 

CONCEPT MAP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Problem statement: (NANDA)

 

Related to: (What is happening in the body to cause the issue?)

 

Manifested by: (Specific symptoms)

 

 

 

 

 

 

.

  LAB VALUES AND INTERPRETETION

 

    
LAB Range Value Value MEANING (If WDL then explain the possible reason for the lab) LAB Range Value Value MEANING
HEMATOLOGY         CHEMISTRY        
CBC         Glucose        
WBC         BUN        
RBC         Cr        
HGB         GFR        
HCT         Na        
PLATLETS         K        
Diff:         CO2        
Polys         Ca        
Bands         Phos        
Lymphs         Amlylase        
Mono’s         Lipase        
Eosin         Uric Acid        
GBC indices         Protein        
MCV         Albumin        
MCH         Cl        
MCHC         Enzymes        
COAG’S         LDH        
PT         CPK        
INR         SGOT        
PTT         SGPT        
ABG’S(V 0R A)         Triponin I        
PH         Myoglobin        
PCO2                  
PO2         Cholesterol        
BASE EX:         UA        
SAT:                  
 

 

 

 

 

URINALYSIS

  

 

 

 

 

Range

  

 

 

 

 

Value

  

 

 

 

 

Value

  

 

 

 

 

Meaning

  

 

 

 

  

 

 

 

 

Findings

  

 

 

 

 

Meaning

  
Color         Gastroccult      
Clarity         Hemoccult      
Sp. Gravity          

SEROLOGY

      
pH         HIV      
Protein         GBS      
Glucose         Gonorrhea/ Chlamydia      
Ketones         Syphilis      
Bilirubin         Hepatitis B      
Occ. Blood         Rubella      
Urobilogen         BLOOD TYPE      
WBC         RH FACTOR      
RBC                
Epithelia         RADIOLOGY      
WBC         EKG      
RBC         CT      
Epith Cell         PET SCAN      
Bacteria         MRI      
Hyal Cast         MRA      
Gran Cast         Ultrasounds      
Leukocytes                
Nitrite                
ACCUCHECKS         Endoscopy      
          Colonoscopy      
                 
Additional information:

 

 

 

 

 

 

 

Universal Self-Care Deficits:    Assessment: (Highlight all abnormal assessment findings)
Vital Signs Admission Reassess
     
    Input:
    Output:

 
Cardiovascular Assessment:

Specialty devices:

 

 

 

Teaching needs:

 Heart Sounds:

 

 

Circulatory Assessment:

 

 

Edema:

 Pain assessment: (PQRST)- Specific area
Respiratory assessment

Special devices:

 

 

 

 

Teaching Needs:

 Lung sounds:

 

 

Pulmonary assessment: (respiratory pattern)

 Cough:

 

 

 

Respiratory treatment and rational for use:
Breast assessment:

 

 

 

 

 

 

Teaching Needs:

 Breast Assessment:

 

 

 

 

Nipple assessment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

Breastfeeding plans:

 

 

 

 

 
Uterine Assessment:

 

 

 

 

 

Teaching needs:

 Location:

 

Firmness:

  

 
GI Assessment:

 

 

 

 

Teaching needs:

 

 

 GI assessment: (observe – auscultate –  palpate)

 

 

 

Alteration in eating or elimination patterns:

 

 Nutrition Metabolic Assessment:

 

 

% of diet taken:

 

Alternative nutritional methods:

 
GU assessment:

 

 

 

Teaching needs:

 Last void:

Due to void:

Alternative urinary elimination method: (if Foley when inserted)

 

Bladder scan

 Assessment of urinary patterns:

Urine assessment (color odor concentration etc.)

 

 

 

 
Lochia Assessment:

 

 

 

Teaching needs:

 

 

 Color:

 

Quantity:

 

Presence of clots:

  
Perineal Assessment:

 

 

 

 

Teaching needs:

 

 REEDA:

 

 

 

 

 

 

 Wound Care:

 

 

 
Thrombophlebitis Assessment:

 

 

 

Teaching needs:

 

  

 

  
Edema Assessment:

 

 

Teaching needs:

 

 

      
Emotional Assessment:

 

 

Teaching needs:

 

 

   Edinburgh Postnatal

Depression Screening:

  
IV Therapies:

IV fluids infusing

 

 IV Site 1: Assessment

 

Date of insertion:                   Change (site or dressing)

 

 IV removal: Reason for removal:
           

Additional information:

 

 

 

 

REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE.  THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.

                                                    PLAN OF CARE:                                                                                        Use your top two priorities

NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals)          Interventions       Patient response        Goal evaluation
NRS DX:

Problem Statement: 

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom)

 

 

 

 

 

 

 

 

Manifested by: (Specific symptoms)

 

 

 

 

 

 

 

 

 

 Short term goal:  Create a SMART goal that relates to hospital stay/shift/day.

 

 

 

 

 

 

 

 

 

 

 

 

Long term goal:  Create a SMART goal that is appropriate for discharge.

 

 This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

Interventions for short-term goal:

1.

2.

3.

 

 

 

 

Interventions for longterm goal:

1.

2.

3.

 

 

 Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

 

 

 

Reassess for short-term goal:

1.

2.

3.

 

 

 

 

 

Reassess for long-term goal:

1.

2.

3.

 

 Was it met or not met there is no partially met.
NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals)           Interventions        Patient response        Goal evaluation
NRS DX:

Problem Statement:

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom?)

 

 

 

 

 

 

 

 

 

 

Manifested by: (specific symptoms)

 

 

 

 

 

 Short term goal:  Create a SMART goal that relates to hospital stay.

Long term goal:  Create a SMART goal that is appropriate for discharge.

 

 This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

 

 Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) Was it met or not met there is no partially met.