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.
==================================
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:
