Professional Documents
Culture Documents
Care Plan Data Collection
Care Plan Data Collection
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Patient Initials:
Primary Diagnosis:
Primary Doctor:
Age:
Code Status:
Sex:
Admission thru: __ Direct Admit __ ER
Pt from: __ Home
__ Long-term care Facility
__ Psychiatric Facility
__ Skilled Nursing Facility
Consults:
Admission Date:
Ht:
Wt:
Allergies:
Vital Signs:
Temp (+ route) _____ Pulse _____ BP _______ Respirations ______ O2 Sat ______ Pain level ______
Diet: ____________________________ Accucheck(s): __________ ___________ ____________ __________
Data Collection
Neurological (include pain, mental status, speech)
Cardiac
1
STC-04-04- 2016
Special
Equipment
Interventions
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
2
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Psychosocial
Site
Gauge
Start
Date
Examination
Intervention(s)
IV solution:
Rate:
Date
CBC
Hemoglobin
Hematocrit
Platelets
RBCs
WBCs
ESR
HgA1c
BMP,CMP
Glucose
Electrolytes
BUN Albumin
Creatinine
T3, T4, TSH
ABGs
pH, PaCO2
HCO-3
PTT,PT/INR
Platelets
3
STC-04-04- 2016
Patients results
What care or
considerations will you
implement?
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Drug Levels
Digoxin
Vanco
Dilantin
Theophylline
Cardiac
Markers
Troponin
Myoglobin
CK-MB, BNP
EKG
Liver
Function
ALT, AST
Amylase
Lipase,
CHOL,
TriglyceridesL
DL, HDL
Urinalysis
Cultures
Wound
Urine
Throat
Blood
X-ray
Reports
CT and/or
MRIs
Ultrasound
Echo/Other
4
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Operative Reports
Item
1. History of falling;
immediate or within 3
months
2. Secondary diagnosis
3. Ambulatory aid
Bed rest/nurse assist
Crutches/cane/walker
Furniture
4. IV/Heparin Lock
5. Gait/Transferring
Normal/bedrest/immobi
le
Weak
Impaired
6. Mental status
Oriented to own ability
Forgets limitations
Total
Scale
No 0
Yes 25
No 0
Yes 15
0
15
30
No 0
Yes 20
Action
0
10
20
0
15
Risk Level
Low Risk
5
STC-04-04- 2016
(Hospital)
ScoringMFS Score
0 - 24
Moderate
Risk
25 - 50
High Risk
51
Good Basic
Nursing
Care
Implement
Standard
Fall
Prevention
Intervention
s
Implement
High Risk
Fall
Prevention
Intervention
s
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
6
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
1.
2.
3.
4.
Completely
Limited
Very Limited
Slightly
Limited
No
Impairment
1.
2.
3.
4.
Constantly
Moist
Very Moist
Occasionally
Moist
Rarely Moist
1.
2.
3.
4.
Bedfast
Chairfast
Walks
Occasionally
Walks
Frequently
1.
2.
3.
4.
Completely
Immobile
Very Limited
Slightly
Limited
No
Limitations
1.
2.
3.
4.
Very Poor
Probably
Inadequate
Adequate
Excellent
1.
2.
3.
Problem
Potential
Problem
No Apparent
Problem
Moisture
Activity
Mobility
Nutrition
Friction
and Shear
Indicate Score:
Total Score
NOTE: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.
(15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk)
CopyrightBarbaraBradenandNancyBergstrom,1988
7
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Medications
Allergies: __________________________________ Medication Times: _________, _______ , ____________
Name of
Medication
Brand and
Generic
Check VS
Check Pain Level
Indication and
Dose
Pharmacological
and
class
route
Name of
Medication
Brand and
Generic
STC-04-04- 2016
Indication and
Pharmacological
class
Dose
and
route
Safe?
Y/N
Nursing Considerations
for THIS medication
(Assessment data, labs,
follow up)
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Nurses Notes
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Date/Time
Notes
Signature
Nurses Notes
Date/Time
STC-04-04- 2016
Notes
Signature
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
STC-04-04- 2016
Enteral
Intake
Time
Amount
(ml)
IV Intake
Time
Amount
(ml)
Output
Time
Type
Amount (mL)
BM
Time
Type
Amount
(mL)
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
Urine
Emesis
Consumed
________%
Fluids
_______ mL
Liquid
Formed
Colostom
y
Drain
Lunch
Consumed
________%
Fluids
_______mL
Urine
Emesis
Liquid
Formed
Colostom
y
Drain
Dinner
Consumed
________%
Fluids
_______mL
Urine
Emesis
Liquid
Formed
Colostom
y
Drain
HS snack
Consumed
________%
Fluids
_______mL
Urine
Emesis
Is this patient
receiving enteral
nutrition?
Yes
No
Urine
Emesis
Liquid
Formed
Colostom
y
Drain
Liquid
Formed
Colostom
y
Drain
Type
_________________
_________________
Tubing Change:
_________
Urine
Emesis
Liquid
Formed
Colostom
y
Drain
Total
Total
Total
* If patient is incontinent, please note whether the void was scant, moderate, or copious.
* Measure all Foley Catheter output (once a shift unless more often is necessary).
* Measure all drain output (once a shift).
* Measure liquid stools and emesis when able to contain
New Orders
1.
2.
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Total
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
3.
Nursing Diagnoses
Nursing Diagnosis:
#1.
1.
Goal:
Interventions:
1. (Assess)
2.
2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)
#2.
1.
1. (Assess)
2.
2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)
STC-04-04- 2016
(Must be complete by post conference to earn a satisfactory clinical grade for the day)
#3.
1.
1. (Assess)
2.
2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)
STC-04-04- 2016