Care Plan Data Collection

8/17/2019 Care Plan Data Collection

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Care Plan Data Collection(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Student Name: _________________________ Clinical Site: _________________ Date: ___________

Patient Initials: Age:

Sex:

Code Status:

Primary Diagnosis:

Past Medical History:

Past Surgical History:

Primary Doctor:

Consults:

Admission thru: __ Direct Admit __ ER

__ Transfer from another hospital __ Transfer from another unit __ ther ________________________________

Pt from: __ Home __ !ong"term care #acility __ Psychiatric #acility __ S$illed %ursing #acility

Admission Date: Ht: &t: Allergies:

Vital Signs: Temp (+ route) _____ Pulse _____ P _______ !espirations ______ "# Sat ______ Pain le$el ______

Diet: ____________________________ Accuc%ec&(s): __________ ___________ ____________ __________

Data Collection Special'uipment

Inter$entions

Neurological (include pain mental status speec%)

Cardiac

1

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!espirator*

astrointestinal

enitourinar*

,usculos&eletal

S&in

2

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Ps*c%osocial

Intra$enous -ines (IVs)

Site auge StartDate

'xamination Inter$ention(s)

IV solution: !ate:

-a.orator* Studies and DiagnosticsTest Date Patient/s results 0%* does t%is

patient %a$e t%is$alue1

0%at does t%is mean2or *our patient1

0%at care orconsiderations 3ill *ou

implement1

CCHemoglobinHematocrit

PlateletsRBC’sWBC’sESRHgA1c

,PC,PGlucoseElectrolytesBUN AlbuminCreatinine!" #" SH

A/s$H" PaC%&HC%'!

PTTPT4IN! Platelets

3

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Drug -e$els

(igo)in*anco(ilantin+eo$+ylline

Cardiac,ar&ersro$onin,yoglobinC-',B" BNPE-G

-i$er5unctionA." AS

Amylase.i$ase"CH%."riglyceri/es.(." H(.

6rinal*sis

CulturesWoun/ Urine+roat

Bloo/78ra*!eports

CT and4or,!I/s

6ltrasound'c%o4"t%er

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"perati$e !eports

,orse 5all Scale (9ospital)

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Ris$ !e'el

M#S Score

Action

Low Risk 0 - 24 Good Basic

NursingCare

ModerateRisk

25 - 50 Implementtandard

!all"re#entionInter#ention

s

$ig% Risk & 5' Implement$ig% Risk

!all"re#entionInter#ention

s

Item Scale Scoring

'( $istor) o* *alling+immediate or wit%in ,mont%s

No 0es 25

2( econdar) diagnosis No 0es '5

,( .m/ulator) aidBed restnurse assistCrutc%escanewalker !urniture

0'5,0

4( I1$eparin Lock No 0es 20

5( Gaitrans*erringNormal/edrestimmo/ile3eakImpaired

0'020

( Mental statusriented to own a/ilit)!orgets limitations

0'5

Total


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Hendrich (( #all Ris$ Model )Reha*+!TC,

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-raden S$in Ris$ Scale

Sensory

Perception

./

Completely!imited

0/

1ery !imited

2/

Slightly!imited

3/

%o(mpairment

(ndicate Score:

Moisture ./

ConstantlyMoist

0/

1ery Moist

2/

ccasionallyMoist

3/

Rarely Moist

Acti'ity ./

-edfast

0/

Chairfast

2/

&al$sccasionally

3/

&al$s#re4uently

Mo*ility ./

Completely(mmo*ile

0/

1ery !imited

2/

Slightly!imited

3/

%o!imitations

%utrition ./

1ery Poor

0/

Pro*a*ly(nade4uate

2/

Ade4uate

3/

E5cellent

#riction

and Shear

./

Pro*lem

0/

PotentialPro*lem

2/

%o ApparentPro*lem

Total Score

%TE: Patients 6ith a total score of .7 or less are considered to *e at ris$ of de'eloping pressure ulcers/).8 or .7 9 lo6 ris$ .2 or .3 9 moderate ris$ .0 or less 9 high ris$,© Copyright Barbara Braden and Nancy Bergstrom, 1988

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,edications

Allergies: __________________________________ ,edication Times: _________ _______ ____________

C%ec& VS C%ec& Pain -e$el C%ec& appropriate la.s C%ec& lood lucose

Name o2 ,edicationrand andeneric

Indication andP%armacological

class

Doseand

route

Sa2e14N

Possi.le Side '22ects(All common and serious;

,in < 2or eac% s*stem)

Nursing Considerations2or T9IS medication

(Assessment data la.s2ollo3 up)

Name o2 ,edication

rand andeneric

Indication andP%armacological

class

Doseand

route

Sa2e14N

Possi.le Side '22ects(All common and serious;

,in < 2or eac% s*stem)

Nursing Considerations2or T9IS medication

(Assessment data la.s2ollo3 up)

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Nurses/ Notes

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Date4Time Notes Signature

Nurses/ Notes

Date+Time %otes Signature

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(nta$e and utputP (nta$e Enteral

(nta$e(1 (nta$e utput -M

Break*ast ime .mount6ml7

ime .mount6ml7

ime )pe .mount 6mL7 ime )pe .mo6mL

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• Consumed

888888889

• !luids

8888888 mL

Lunc%

• Consumed

888888889

• !luids

8888888mL

:inner

• Consumed

888888889

• !luids

8888888mL

$ snack

• Consumed

888888889

• !luids

8888888mL

Is t%is patientrecei#ing enteralnutrition;es No

)pe 88888888888888888 88888888888888888

•

• u/ing C%ange<

888888888

=rine>mesis

:rain

Li?uid

!ormed

Colostom)

=rine>mesis

:rain

Li?uid

!ormedColostom

)

=rine>mesis

:rain

Li?uid

!ormedColostom

)

=rine>mesis

:rain

Li?uid

!ormedColostom

)

=rine>mesis

:rain

Li?uid

!ormedColostom

)

=rine>mesis

:rain

Total

Li?uid

!ormedColostom

)Total

Total Total

; (f patient is incontinent< please note 6hether the 'oid 6as scant< moderate< or copious/; Measure all #oley Catheter output )once a shift unless more often is necessary,/; Measure all drain output )once a shift,/; Measure li4uid stools and emesis 6hen a*le to contain

%e6 rders

1.

2.

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3.

%ursing Diagnoses

%ursing Diagnosis: =oal: (nter'entions:

>./ ./

0/

./ )Assess,

0/ )Do,

2/ )Colla*orate,

3/ )Medication,

8/ )Safety,

7/ )Teach,

>0/ ./

0/

./ )Assess,

0/ )Do,

2/ )Colla*orate,

3/ )Medication,

8/ )Safety,

7/ )Teach,

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>2/ ./

0/

./ )Assess,

0/ )Do,

2/ )Colla*orate,

3/ )Medication,

8/ )Safety,

7/ )Teach,

STC-04-04- 2016

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Care Plan Data Collection

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