El Camino School of Nursing

Care Plan

Patient Information

Pt Initials __________ Age: ______ Sex: ______ Room #: _______ Culture/Ethnicity:_______________

Diagnosis: ________________ Surgical Procedure: _________________ Allergies: ____________________

Family/Support System: ___________________ Medical History: ___________________________________

Gas Exchange:

BP ___________ P: __________ T: ___________ Resp: ___________ O2 Sat: ____________

Pain: ____________ VS Q: __________ O2: __________L/min Via: Nasal Cannula / Mask / Room Air

Respiratory Therapy Q: ______ hours Cardiac Rhythm: ________________

Elimination:

I&O: _________ Last BM: ___________ Urine _________ Pt is: Continent / Incontinent

Elimination Devices: Foley Catheter / Condom Catheter / Colostomy / Urostomy / Ileostomy / Nephrostomy

Tissue Integrity:

Skin Breakdown: Pressure Ulcer / Incision / Laceration/ Blisters / Vascular Ulcer Moisture-Related Dermatitis.

Describe Breakdown and Location: _____________________________________________________________

__________________________________________________________________________________________

Dressing Changes: __________________________________________________________________________

Mobility/Sleep:

Ambulatory / Ambulatory with Standby Assist / Bed rest / Fully Dependent

Assistive Devices: Walker / Cane / Wheelchair Pattern of Sleep: ______________ hours

Nutrition:

Weight: ___________kg/lbs Height: __________cm/inches Diet: ___________________________________

Consistency of Diet: Regular / Soft / Mechanical Soft / Pureed / Fluids: Thin or Thickened (Nectar / Honey)

IV Fluids: (Type and # of mLs per hour) _____________________ Fluid Restriction: __________________

IV site: Location ____________ Next site change due: _____________ Blood Sugar Checks _____________
El Camino College 1 Fall 2018
El Camino School of Nursing
Diagnosis:_____________________________ Latest vitals before med administration: BP: _____ HR: _____ T: _____ R: ____ Pain: ___
History: ________________________________________________________ Allergies: ________________________________________

MEDICATION RESEARCH
DRUG ORDER CLASSIFICATION & SIDE EFFECTS WHY CLIENT IS DESIRED IS DRUG NURSING
BRAND/GENERIC MECHANISIM OF ADVERSE REACTIONS TAKING DRUG? EFFECT EFFECTIVE? CONSIDERATIONS/Health
DOSE, ROUTE ACTION DRUG INTERACTIONS PROVIDE Teaching Needed
FREQUENCY DATA
IS DOSE SAFE?

El Camino College 2 Fall 2018

El Camino School of Nursing

LABORATORY TEST or DIAGNOSTIC PROCEDURE

Action by the student

Lab Test or Diagnostic Normal Range or Result Result Trends and Implications Why was the test nurse before test?
Procedure ordered for this client? Action by the student
nurse after test?

El Camino College 3 Fall 2018

El Camino School of Nursing Medical Diagnosis:

History:
Assessments:

Priority NANDA Diagnosis #1: Priority NANDA Diagnosis #2: Priority NANDA Diagnosis #3:

Goal: Goal: Goal:

Interventions: Interventions: Interventions:

1. Monitor 1. Monitor 1. Monitor

2. Manage 2. Manage 2. Manage

3. Teach 3. Teach 3. Teach

Evaluation: Evaluation: Evaluation:

El Camino College 4 Fall 2018