NSG528 Medical Surgical Nursing II Care Plan & Client Concept Map Packet

Posted: August 25th, 2024

Nursing Care Plan Part I: Basic Conditioning Factors Date: 08/25/2024

A. Patient identifiers:

Physician(s): Dr. Emily Carter (Primary Care), Dr. Michael Rodriguez (Endocrinologist)

Age: 42 Gender: Female Ht: 5’6″ (168 cm) Wt: 190 lbs (86 kg) Code Status: Full Code

Isolation: None

Development Stage (Erikson): Generativity vs. Stagnation

Rationale: At 42, Sarah is in the middle adulthood stage. She’s balancing work and family responsibilities, which aligns with Erikson’s concept of generativity. Her struggle with health management and desire to learn more about her conditions suggest she’s working through this stage, trying to contribute positively to her family and society while managing personal challenges.

Health States

Date of admission: 08/24/2024

Activity level: Sedentary

Diet: Regular, low sodium, diabetic

Fall risk: Low

Client’s description of health status (define chronic state):

Sarah reports feeling overwhelmed managing her multiple chronic conditions. She experiences increased fatigue, difficulty controlling blood sugar, and occasional shortness of breath. She describes her health as “declining” and expresses frustration with her inability to maintain a consistent healthy lifestyle.

Admitting Diagnosis:

Type 2 Diabetes Mellitus with poor glycemic control

Hypertension

Obesity

Fatigue

Allergies: Penicillin (rash)

Client’s past medical surgical history (include dates):

Type 2 Diabetes Mellitus (diagnosed 2019)

Hypertension (diagnosed 2021)

Obesity (ongoing)

Appendectomy (2005)

Cesarean section (2010)

Completed therapies:

Diabetes education course (2019)

Weight management program (2022)

Current therapies:

Medication management for diabetes and hypertension

Annual diabetic eye exam

Regular blood glucose monitoring

Quarterly HbA1c testing

Socio-cultural Orientation

Cultural and Ethnic Background: Caucasian, American

Socialization: Sarah is married with two teenage children. She reports having a small circle of friends but limited time for social activities due to work and family responsibilities.

Family system Elements (Support system): Husband (John, 44), supportive but also works full-time. Two children (Emma, 16 and Alex, 14) who are in high school. Sarah’s parents live nearby and offer occasional support.

Spiritual: Identifies as Christian, attends church occasionally

Occupation (across the lifespan):

Current: Accountant (10 years)

Previous: Bookkeeper (5 years), Office Assistant (3 years)

Patterns of living: (define past and current)

Past: More active lifestyle, participated in recreational sports, cooked meals at home regularly

Current: Sedentary lifestyle due to desk job, relies more on convenience foods, struggles to find time for exercise

Barriers to independent living: None at present, but current health trajectory could lead to complications that may impact independence in the future if not addressed.

Part II: Medications

ALLERGIES: Penicillin (rash)

Medication & Classification Dosage Purpose/Mechanism of Action Contraindications, Adverse Reactions/Side Effects; Risk Factors, Nursing Implications; & Patient Education **Relevant Research Findings/Evidence to support treatment for this client.

Metformin

(Biguanide) 1000mg twice daily Purpose: To lower blood glucose levels in type 2 diabetes.

Mechanism: Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity. Contraindications: Severe renal impairment, metabolic acidosis.

Adverse reactions: GI disturbances, lactic acidosis (rare).

Risk factors: Renal impairment, elderly.

Nursing implications: Monitor renal function, educate about hypoglycemia symptoms.

Patient education: Take with meals, report severe GI symptoms, importance of regular blood glucose monitoring. A 2019 systematic review in Diabetes Care found that metformin remains the most effective first-line treatment for type 2 diabetes, with benefits in glycemic control, weight management, and cardiovascular risk reduction.

(American Diabetes Association. “9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021.” Diabetes Care, 2021)

Lisinopril

(ACE Inhibitor) 10mg once daily Purpose: To lower blood pressure and protect kidney function in diabetic patients.

Mechanism: Inhibits the conversion of angiotensin I to angiotensin II, leading to vasodilation and decreased blood pressure. Contraindications: Pregnancy, history of angioedema.

Adverse reactions: Dry cough, hyperkalemia, dizziness.

Risk factors: Renal artery stenosis, volume depletion.

Nursing implications: Monitor blood pressure and renal function, assess for cough.

Patient education: Take consistently, report persistent cough or dizziness, avoid pregnancy. The HOPE study demonstrated that ACE inhibitors like lisinopril reduce cardiovascular events in high-risk patients, including those with diabetes.

(Heart Outcomes Prevention Evaluation Study Investigators. “Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.” New England Journal of Medicine, 2000)

Atorvastatin

(HMG-CoA Reductase Inhibitor) 20mg once daily Purpose: To lower cholesterol levels and reduce cardiovascular risk.

Mechanism: Inhibits HMG-CoA reductase, reducing cholesterol synthesis in the liver. Contraindications: Active liver disease, pregnancy.

Adverse reactions: Muscle pain, liver enzyme elevations.

Risk factors: Elderly, concomitant use of certain medications.

Nursing implications: Monitor liver function tests, assess for muscle pain.

Patient education: Take in the evening, report muscle pain or weakness, avoid grapefruit juice. The CARDS study showed that atorvastatin significantly reduces the risk of cardiovascular events in patients with type 2 diabetes, even those with relatively low LDL cholesterol levels.

(Colhoun HM, et al. “Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS).” Lancet, 2004)

Part III: LABS

Lab Initial Results

Date & Time Current Results Date/Time Normal Range How does this lab relate to your patient’s care?

Why was it drawn? Was the result expected? If abnormal- why?

Blood Pressure 140/90 mmHg

08/24/2024 09:00 142/88 mmHg

08/25/2024 07:30 <130/80 mmHg Drawn to monitor hypertension. Slightly elevated, indicating suboptimal control. Expected due to ongoing management challenges. HbA1c 7.8% 08/24/2024 10:30 Not repeated <7.0% Indicates suboptimal diabetes control over past 3 months. Drawn to assess long-term glucose management. Higher than target, reflecting reported difficulty in glycemic control. Fasting Blood Glucose 145 mg/dL 08/24/2024 07:00 138 mg/dL 08/25/2024 07:00 70-100 mg/dL Monitors daily glucose control. Elevated, confirming poor glycemic control. Slight improvement, but still above target range. Total Cholesterol 210 mg/dL 08/24/2024 10:30 Not repeated <200 mg/dL Slightly elevated, indicating increased cardiovascular risk. Drawn as part of lipid panel for cardiovascular risk assessment in diabetic patient. LDL Cholesterol 130 mg/dL 08/24/2024 10:30 Not repeated <100 mg/dL Above target for diabetic patients. Indicates need for more aggressive lipid management to reduce cardiovascular risk. HDL Cholesterol 45 mg/dL 08/24/2024 10:30 Not repeated >50 mg/dL (women) Slightly low, indicating reduced cardioprotective effect. Common in diabetic patients with metabolic syndrome.

Triglycerides 180 mg/dL

08/24/2024 10:30 Not repeated <150 mg/dL Elevated, common in diabetic patients. Indicates need for improved glycemic control and lifestyle modifications. Serum Creatinine 0.9 mg/dL 08/24/2024 10:30 Not repeated 0.6-1.1 mg/dL (women) Within normal range. Drawn to assess kidney function, important for diabetic patients and those on ACE inhibitors. eGFR >90 mL/min/1.73m²

08/24/2024 10:30 Not repeated >90 mL/min/1.73m² Normal kidney function. Important to monitor in diabetic patients due to risk of diabetic nephropathy.

ALT 28 U/L

08/24/2024 10:30 Not repeated 7-56 U/L Within normal range. Drawn to assess liver function, important for patients on statins.

AST 25 U/L

08/24/2024 10:30 Not repeated 10-40 U/L Within normal range. Part of liver function panel, relevant for statin therapy.

Diagnostic Test (i.e. CXR, CT, MRI, Doppler, ECHO, ECG, etc.)

Date Test Type Results Significance (why was it ordered, for what problem)

08/24/2024 ECG Normal sinus rhythm, no acute changes Ordered due to patient’s risk factors (diabetes, hypertension, obesity) and complaint of occasional shortness of breath. Results show no acute cardiac issues.

08/24/2024 Chest X-ray Clear lung fields, no acute cardiopulmonary process Ordered to evaluate reported shortness of breath. Results show no acute pulmonary issues, suggesting breathlessness may be related to deconditioning or obesity.

IV solution or PB meds Location Reason for IV and/or Fluids. List any interventions needed or completed

N/A N/A Sarah does not currently require IV fluids or medications.

Nutrition (diet orders, supplements, tube feeding, restrictions, etc.) and why are they ordered.

Sarah is on a regular, low sodium, diabetic diet. This diet is ordered to help manage her diabetes and hypertension. It aims to control carbohydrate intake, reduce sodium to help lower blood pressure, and promote overall health. The dietitian has recommended smaller, more frequent meals to help with blood sugar control.

Is this patient on telemetry? Explain why they are on telemetry and the rhythm they are in?

Sarah is not currently on telemetry. While she has risk factors for cardiovascular disease (diabetes, hypertension, obesity), her ECG was normal and she has not shown any acute cardiac symptoms that would necessitate continuous monitoring at this time.

Head to Toe Physical Assessment

POLST/Code Status: Full Code

VS 7:30: Temperature 98.6°F Pulse 78 Respirations 18 BP 142/88 Pain 0/10

VS 11:30: Temperature 98.4°F Pulse 82 Respirations 20 BP 138/86 Pain 0/10

GENERAL SURVEY

How does the client look? Age 42 Female Body Build: Obese

Height 5’6″ Weight 190 lbs Well groomed

Facial Expression: Anxious

NEUROLOGICAL

(LOC) Level of

Consciousness Alert Awake

Oriented x 4: Person Place Time Event Response to touch/voice

Eyes Unaided sight Glasses Snellen 20/30

Pupils Equal Round Reactive to light Accommodates Brisk

Pupil size before light 4mm Pupil size after light 2mm

Ears Unaided hearing

Extremities Hand grips +5 equal Foot pushes +5 equal

Cranial Nerves – intact All cranial nerves intact

Pain No pain reported

CARDIOVASCULAR

Skin / Mucous Membranes Pink

Radial and Pedal Pulses Radial: Palpable (L/R) Pedal: (DP PT) Palpable (L/R)

Apical Radial Pulses No pulse deficit noted

Carotid Pulses Right +2 Left +2 No Thrill No Bruit

Capillary Refill Normal (<3 Sec) 2 sec Jugular Neck Veins Not visible Edema Absent Calf Tenderness Denies Negative Homan’s sign Heart Rhythm/ Sounds – S1S2 Regular S1S2 normal No Murmur No Extra sounds Telemetry: N/A IV N/A RESPIRATORY Respirations Regular Even Unlabored Symmetrical Lung Sounds Clear LUL RUL LLL RLL RML Anterior Posterior Cough None Oxygen Room air Pulse ox 98% Respiratory Treatments Incentive Spirometer (IS): 1500ml frequency 10x/hr hold for 3 seconds # of times 10 ALLERGIES Penicillin (rash) BLOOD GLUCOSE 138 mg/dL (fasting) GASTROINTESTINAL Oral Teeth intact Mucous Membranes: intact moist Abdomen: Inspect Auscultate Percuss Palpate Soft Round Obese Nondistended Non Tender Bowel Sounds RLQ RUQ LUQ LLQ Normoactive NG/ GT/ JT None Bowel Movement Continent last BM 08/24/2024 Nutrition Diet: Regular, low sodium, diabetic % eaten Breakfast 75% Self feed GENITOURINARY Urine Continent Color pale yellow Clear Intake and Output PO intake 1200mL Urine output 1000mL Fluid restriction None Genitalia Female LMP 2 weeks ago MUSCULOSKELETAL Mobility ADLs independent Muscle treatment None CMST Circulation, Motion, Sensation, Temperature normal in all extremities Contractures Not present Amputation No ROM Full ROM in all extremities Mobility Turns self Sits independently Stands independently Walks independently Risk for Falls Low risk, no interventions needed INTEGUMENTARY Appearance Intact Color: normal for ethnicity Skin Warm Dry Wound Dressing Pressure Ulcers None ISOLATION None PSYCHOSOCIAL Behavior Cooperative Pleasant Restraints None Language spoken English = speaks and understands Ambulation status for your patient. What interventions would ensure patient safety with mobility? Sarah is independently ambulatory. To ensure her safety: Encourage her to wear non-slip footwear. Ensure pathways in her room and to the bathroom are clear of obstacles. Instruct her to use handrails in the hallways and bathroom when available. Encourage her to call for assistance if feeling dizzy or unsteady. What education have you seen your nurse preceptor discuss with the patient? Why was this material discussed? (new med, discharge, etc) The nurse preceptor discussed: Diabetes management: Importance of regular blood glucose monitoring, proper timing of medications, and recognizing signs of hypo/hyperglycemia. This was discussed due to Sarah’s suboptimal glycemic control. Dietary recommendations: Explained the benefits of the prescribed diet for managing both diabetes and hypertension. This was crucial given Sarah’s multiple chronic conditions and reported struggle with diet adherence. Client Concept Map Part I: Assessment/Recognize Key Assessment Findings: 42-year-old female with Type 2 Diabetes, Hypertension, and Obesity Suboptimal glycemic control (HbA1c 7.8%, FBG 138 mg/dL) Elevated blood pressure (142/88 mmHg) BMI 32 (Obese) Fatigue and occasional shortness of breath Sedentary lifestyle due to desk job Difficulty maintaining consistent diet and exercise routine High stress levels from work and family responsibilities Dyslipidemia (elevated total cholesterol, LDL, and triglycerides; low HDL) Client Concept Map Part II: Concept Map Central Issue: Chronic Disease Management Connected Issues: Diabetes Management Suboptimal glycemic control Medication adherence Blood glucose monitoring Dietary challenges Cardiovascular Health Hypertension Dyslipidemia Obesity Sedentary lifestyle Lifestyle Factors Work-related stress Family responsibilities Time management Nutrition choices Psychosocial Aspects Feeling overwhelmed Knowledge deficit about condition management Motivation for lifestyle changes Physical Symptoms Fatigue Occasional shortness of breath Client Concept Map Part III: Nursing Diagnoses & Plan Priority Nursing Diagnoses: Ineffective Health Maintenance related to knowledge deficit and complex treatment regimen as evidenced by suboptimal glycemic control and difficulty adhering to lifestyle modifications. Imbalanced Nutrition: More than body requirements related to sedentary lifestyle and poor dietary choices as evidenced by BMI of 32 and dyslipidemia. Activity Intolerance related to sedentary lifestyle and obesity as evidenced by fatigue and occasional shortness of breath. Ineffective Coping related to multiple chronic health conditions and life stressors as evidenced by reported feelings of being overwhelmed. Plan for Top Priority Diagnosis: Ineffective Health Maintenance Outcomes: Client will demonstrate improved glycemic control as evidenced by fasting blood glucose levels between 80-130 mg/dL within 1 week. Client will verbalize understanding of diabetes management strategies, including medication adherence, dietary guidelines, and importance of physical activity by discharge. Interventions: Provide comprehensive diabetes education, including: Proper use of glucose meter and interpretation of results Timing and administration of medications Signs and symptoms of hypo/hyperglycemia and appropriate actions Importance of consistent carbohydrate intake and meal timing Collaborate with dietitian to develop a personalized meal plan that addresses both diabetes and cardiovascular health. Assist client in creating a realistic exercise plan, starting with short, achievable goals (e.g., 10-minute walks twice daily). Teach stress-management techniques such as deep breathing exercises and progressive muscle relaxation. Provide resources for ongoing diabetes support, such as support groups or diabetes management apps. Evaluation: Monitor daily fasting blood glucose levels and trend over time Assess client’s verbal understanding of diabetes management strategies through teach-back method Review client’s food and activity log to ensure adherence to recommendations Schedule follow-up appointments with primary care provider and endocrinologist Student Evaluation of Clinical Performance After reflecting on the clinical performance today, the critical thinking utilized included: Comprehensive assessment: Gathering and analyzing data from multiple sources (patient interview, physical assessment, lab results) to form a holistic view of the patient’s condition. Prioritization: Identifying the most pressing health issues among multiple chronic conditions and psychosocial factors. Integration of knowledge: Applying understanding of pathophysiology, pharmacology, and evidence-based practice to develop appropriate interventions. Patient-centered care: Considering Sarah’s lifestyle, preferences, and challenges when developing the care plan. Interdisciplinary collaboration: Recognizing the need for input from various healthcare professionals (e.g., dietitian, endocrinologist) for optimal patient care. Areas for improvement in the next clinical day: Enhance motivational interviewing skills to better engage patients in their care plan and lifestyle modifications. Develop more in-depth knowledge of current diabetes management guidelines and emerging treatments. Practice creating more detailed, individualized patient education materials that address specific patient needs and learning styles. Improve time management skills to balance comprehensive care with efficiency in a clinical setting. Seek opportunities to observe and participate in interdisciplinary team meetings to better understand collaborative care approaches for complex chronic conditions.

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NSG528 Medical Surgical Nursing II Care Plan & Client Concept Map Packet

Case Study.
Patient: Sarah Johnson

Age: 42

Gender: Female

Medical History:

Type 2 Diabetes (diagnosed 5 years ago)

Hypertension (diagnosed 3 years ago)

Obesity (BMI 32)

Family history of heart disease (father had a heart attack at 55)

Current Condition:

Sarah has been experiencing increased fatigue, difficulty managing her blood sugar levels, and occasional shortness of breath over the past month. She reports feeling overwhelmed with her health management and has been struggling to maintain a consistent exercise routine and healthy diet.

Medications:

Metformin 1000mg twice daily (for diabetes)

Lisinopril 10mg once daily (for hypertension)

Atorvastatin 20mg once daily (for cholesterol management)

Recent Diagnostic Results:

Blood Pressure: 142/88 mmHg (slightly elevated)

HbA1c: 7.8% (indicating suboptimal diabetes control)

Fasting Blood Glucose: 145 mg/dL

Total Cholesterol: 210 mg/dL

LDL Cholesterol: 130 mg/dL

HDL Cholesterol: 45 mg/dL

Triglycerides: 180 mg/dL

Additional Information:

Sarah works as an accountant, which involves long hours sitting at a desk.

She is married with two teenage children.

She reports high stress levels due to work and family responsibilities.

Sarah has attempted to lose weight in the past but has struggled to maintain a consistent diet and exercise plan.

She has expressed interest in learning more about managing her conditions but feels overwhelmed by the amount of information available.
—–

Assignment: NSG528 Medical Surgical Nursing II Care Plan & Client Concept Map  

Instructions:  

Complete

a comprehensive care plan according to your scheduled due dates. Be thorough.

Read the prompts and directions. Be detail-oriented.  

 

Care

Plan/Client Concept Map Components: 

·               Care Plan Part I:

Basic Conditioning Factors  

·               Care Plan Part II:

Medications – must include evidence to support use of 3 most relevant

medications in client case 

·               Care Plan Part III:

Diagnostic Studies & Interpretation 

·               Care Plan Part IV:

Physical Assessment  

·               Client Concept Map

Part I: Assessment/Recognize  

·               Client Concept Map

Part II: Concept Map

·               Client Concept Map

Part III: Nursing Diagnoses & Plan  

Nursing

Care Plan Part I: Basic Conditioning Factors

 Date:                                                        

A.

Patient identifiers:

Physician

(s):

Age:                        Gender:              Ht:               Wt.               Code Status:

Isolation:

Development

Stage (Erikson): Give the rational for your evaluation

 

 

Health

States

 

Date of

admission:

Activity

level:                                                                Diet:

Fall

risk

 

Client’s

description of health status (define chronic state)

 

 

Admitting

Diagnosis

 

 

Allergies:

(include type of reaction)

 

 

Client’s

past medical surgical history (include dates)

 

 

 

Completed

therapies:

 

 

 

 

Current

therapies:

Socio-cultural

Orientation

 

Cultural

and Ethnic Background

 

Socialization:

 

Family

system Elements (Support system)

 

Spiritual:

 

Occupation

(across the lifespan)

 

Patterns

of living: (define past and current

 

Barriers

to independent living

 

Part II: 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. (May

include additional copies of this form as needed)

** Must include evidence to

support use of 3 most relevant medications in client case.

ALLERGIES:

Medication & Classification

Dosage

Purpose/Mechanism of Action

Contraindications, Adverse Reactions/Side Effects; Risk Factors,

Nursing Implications; & Patient Education

**Relevant Research Findings/Evidence to support treatment for this

client.

Link to Article/Evidence Below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part III:

LABS

Include all labs resulted in the past 24

hours. Compare admission

labs with most recent labs. Report on any single resulted lab (ex: one D-dimer done on day 3 of

admission) 

 

Lab

Initial Results

Date & Time

Current Results Date/Time

Normal Range

How does this lab relate to your patient’s

care?

Why was it drawn? Was the result

expected? If abnormal- why?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnostic Test (i.e. CXR, CT, MRI,

Doppler, ECHO, ECG, etc.)

Date

Test Type

Results

Significance (why was it ordered, for

what problem)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV

solution or PB meds

Location

Reason

for IV and/or Fluids. List any interventions needed or completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nutrition (diet orders, supplements, tube feeding, restrictions, etc.)

and why are they ordered.   

 

 

 

 

Is this patient on telemetry? Explain why they are on telemetry and the

rhythm they are in?

 

 

  

 

 

Head

to Toe Physical Assessment 

POLST/Code Status   VS 7:30:

Temperature                     Pulse             Respirations                          BP          /                              Pain    /10

                                  VS 11:30:Temperature                   Pulse             Respirations                          BP          /                              Pain    /10

GENERAL SURVEY

 

How does

the client look?

Age___________           Male/Female         Body Build:   Thin     

Cachectic      Obese      WNL

Height___________  Weight____________                      Well groomed         Poorly Groomed

Facial

Expression:    Anxious     Happy    

Sad     Angry

NEUROLOGICAL

 

(LOC) Level

of

Consciousness

Alert      Awake      Lethargic      Obtunded       Stupor      Comatose      Confused       Decerebrate       Decorticate       

Oriented x

4:     Person  Place 

Time  Event    Response to touch/voice

Eyes

Unaided

sight        Glasses      Contact lens       Implants       Prosthesis       Snellen  20/              Blind

Pupils

Equal

           Round      

Reactive to light     

Accommodates      Sluggish      Brisk      Nonreactive to light     Consensual

Pupil size

before light ______mm  Pupil size after

light ______mm

Ears

Unaided

hearing       Hard of hearing        Deaf        Hearing aid         Implant        Cerumen        Drainage

Extremities

Hand  grips   

+1 +2 +3 +4 +5     equal  unequal            Foot pushes     +1 +2 +3 +4 +5    equal 

unequal

Cranial

Nerves – intact

I(smell)         II(vision)         III+IV+VI(eye movement)        V(sensation of face/oral)           VII (facial movement/taste)      

VIII

(hear/balance)      IX

(taste/swallow)      X

(chew/gag/speech)       XI (shrug/turn

head)        XII(tongue movement)

Pain

Character       Onset       Location        Duration       Severity        Pattern       Associated Factors    COLDSPA

CARDIOVASCULAR

 

Skin /

Mucous Membranes

Pink                

Pale                 Cyanotic               Jaundiced               Ruddy                 Flushed              Diaphoretic

Radial and

Pedal Pulses

Radial:

Palpable (L/R)            Absent

(L/R)           Pedal: (DP PT)          Palpable (L/R)         Absent (L/R) 

Apical

Radial Pulses

(2 people

simultaneously)                  Apical

and Radial                          

Pulse Deficit

Carotid

Pulses

(DO NOT

TAKE AT SAME TIME)      Right             Left             Thrill                 Bruit

Capillary

Refill

Normal (<3 Sec)                 ______sec

Jugular

Neck Veins

Not

visible           Visible

Edema

Absent             Present: location                       +1 +2 +3 +4   Anasarca             Pitting        Non Pitting

Calf

Tenderness

Denies    Positive Homan’s sign    R L  

calf size R____  L_____             (team leader or charge nurse

notified)

Heart Rhythm/

Sounds –

S1S2

Regular       Irregular       Murmur        Extra sounds        Strong         Faint             Muffled

Telemetry:          rhythm ___________________     Pacemaker      Defibrillator       location

IV

Solution_______________                 Rate     ____ml/hr             Pump

Site

location (be specific)                  ______________________________________

Site appearance:  Clear   

Edema     Erythema      Tender      Pallor

Dialysis

access: type __________      

Thrill     Bruit     Location:___________  Appearance:____________

RESPIRATORY

 

Respirations

Regular   Irregular     Even   

Uneven     Unlabored     Labored     Symmetrical    Asymmetrical

Lung Sounds

Clear      LUL        RUL       LLL

       RLL        RML      

Anterior      Posterior

Wheezes  location__________     Rales/crackles   location__________     Rhonchi    location ________

Nasal flaring    Sternal retraction    Intercostal retraction

Do lung

sounds improve with cough and deep breath?  

If no, report to team leader

Cough

None    

Nonproductive      Dry       Moist        Productive      Sputum:amount               color         frequency

Oxygen

Room air                     Pulse ox ______          O2 at_____L/min             Nasal Cannula              Mask                          

Tent              CPAP            BIPAP

Respiratory

Treatments

Incentive Spirometer (IS):

ml______ frequency _______hold for ___ seconds     # of times______

HHN          medication                Bipap       Ventilator?  TV                 rate           02%       other

ALLERGIES

 

BLOOD GLUCOSE

 

GASTROINTESTINAL

 

Oral

Teeth      Dentures      Caries      Dysphagia         Mucous Membranes:     intact     moist    

dry     pale     leukoplakia  

Abdomen:     Inspect   

Auscultate  Percuss

Palpate

Soft      Round     Flat    

Scaphoid     Obese      Firm    

Hard     Nondistended     Distended      Tender    Non Tender   Location:

Bowel

Sounds

RLQ       RUQ      LUQ

      LLQ        Normoactive    

Hypoactive     Hyperactive      Absent

NG/ GT/ JT

None        Type of tube _____      patent        nonpatent

Suction:

low        high              Color of drainage                                amount                        

Bowel

Movement

Continent         

Incontinent       last BM             Color                  Size             Consistency           Ostomy          Stool

Nutrition

Diet___________    % eaten Breakfast____ Lunch_____

NPO?  Why___________           

Self feed    Needs assistance       Thickened liquids:  honey 

nectar    pudding           Tube Feed_________________  

GENITOURINARY

 

Urine

Continent        Incontinent         Catheter type _______________      Patent       Nonpatent________________    

Color_________________ 

Clear        Cloudy     

Sediment        Burning         Frequency

Intake and

Output                        

PO/Oral/Tube Feed

intake____________    IV

intake____________    Urine

output_________    Other output        

Fluid restriction                          Total I&O  + /- 

________________

Genitalia

Male             Female              vaginal discharge                LMP                    post partum                                                  

MUSCULOSKELETAL

 

Mobility

ADLs

independent or assisted with

_________________________________________________

Muscle

treatment

None     Cast     Brace    

Splint    Location      Elevate          Traction – type                   traction wt:

CMST

Circulation: color, pulses, cap

refill      Motion            Sensation           Temperature          

RA                LA                   RL                    LL                      Antiembolitic Hose:knee/thigh

Contractures

Not

present         Present – which

extremity?                                        What

% decreased?

Amputation

No          Yes        Location   _______________________________

ROM

AROM    AAROM       PROM   

CPM     Limited   location___________________

Mobility

Turns self      Sits independently      Dangles        Stands independently        Walks independently                  

Ambulatory assistance: Gait

belt    Cane     Walker     Crutches     Braces     Wheelchair     Gerichair

Walks:  distance                 frequency                 tolerance                   PT  OT 

RNA

Risk for

Falls

Bed

alarm   Chair alarm   1 or 2 Person Transfer   Floor pad    Side Rails    Mechanical Lift    Slide Board

INTEGUMENTARY

 

Appearance

Intact    Color___________       Pallor      Rash      Bruise     Lesions      Scar  

Location _________________________

Turgor_____seconds    Site___________    

Skin

Warm              Hot              Cool

           Cold              Dry             Moist

Wound Dressing

Pressure

Ulcers

None      Surgical site – Location                          Well

approximated        Sutures    Staples  

Steristrips

Dressing:   Dry/intact   Non-intact    Change: 

yes  no                          

Drainage: Color                            Amount___________                       Odor_________

Wound appearance                     Drain type  _________ 

Amount______

Stage                  Location              Size                      Tunneling              Eschar               Slough

Stage                  Location              Size                      Tunneling              Eschar               Slough

Stage                  Location              Size                      Tunneling              Eschar               Slough

ISOLATION

 

Type                      Culture                      Site                                           Type                    Culture                      Site                                             

PSYCHOSOCIAL

 

Behavior

Cooperative         Uncooperative          Pleasant           Withdrawn            Combative         Other_______________

Restraints

None

     Chemical        Physical: type                          location                     

CMST of

extremity   RA    LA   

RL     LL           Frequency Checked________________     See Restraint Form

Language

spoken

English =

speaks and understands        

other_________________  

Interpreter

 

Ambulation status for your patient. What interventions would ensure

patient safety with mobility?

 

 

  

 

 

 

 

 

What education have you seen your nurse preceptor discuss with the

patient? Why was this material discussed? (new med, discharge, etc)

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

STUDENT

EVALUATION OF CLINICAL PERFORMANCE

(please list

specific examples for each clinical experience):

After reflecting on your clinical performance today, what

critical thinking did you utilize and how can you improve on that in your next

clinical day?

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT CONCEPT MAP PART II (EXAMPLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT CONCEPT MAP PART II Recognize &

Analyze Cues

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT CONCEPT MAP- PART III-PRIORITY PATIENT PROBLEMS PLAN OF CARE: (EXAMPLE)

 

ANALYZE CUES

PRIORITIZE HYPOTHESIS

 

GENERATE SOLUTIONS

 

TAKE ACTIONS

EVALUATE OUTCOMES

 

Analyze Cues: Organize and linking the recognized cues to the

client’s clinical presentation.

 

What client conditions are consistent with the

cues?

 

 

 

What other information would help establish

the significance of a cue or set of cues?

 

Subjective and Objective Data

 

 

 

 

 

 

 

 

Evaluating and ranking hypotheses according to priority

(urgency, likelihood, risk, difficulty, time, etc.)

 

Based on analysis, which explanations are

most/least likely or are the most serious?

 

 

 

 

This is

the identification of your priority patient problems. Identify your top 4

patient priorities here:

 

 

 

 

 

 

Identify expected outcomes and using hypotheses to define a

set of interventions for the expected outcomes.

 

What are the desired outcomes related to your #1 priority patient problem?

 

List a

minimum of two.

 

 

 

What should be avoided?

 

 

 

 

 

 

 

 

 

 

Implementing the solution(s) that addresses the highest

priorities.

 

 

*What interventions can achieve the outcomes

listed for your #1 priority patient problem?

 

List a

minimum of three interventions for each outcome. (note: potential solutions could include

collecting additional information).

 

 

How should each of the selected interventions

be accomplished (performed, requested, administered, communicated, taught,

documented)?

 

Comparing observed

outcomes against expected outcomes.

 

What signs point to (or would point to) improving

or declining status for each of the selected interventions?

 

 

 

Based on the signs noted, were the

interventions effective?

 

 

Would other interventions have been more

effective?

 

 

 

 

 

*note:

the selection of interventions is part of generating

solutions – the actual implementation of interventions is a part of taking action.

Cite your

references:

 

 

 

CLIENT CONCEPT MAP- PART III-PRIORITY PATIENT PROBLEMS PLAN OF CARE

ANALYZE CUES

PRIORITIZE HYPOTHESIS

 

GENERATE SOLUTIONS

 

TAKE ACTIONS

EVALUATE OUTCOMES

 

 

Subjective Data

 

 

 

 

 

 

 

 

Objective Data

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cite your

references: