Nursing Care Plan and Evaluation

The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. All nursing care plans must be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard in each clinical course. The grading rubric must be attached – last page of nursing care plan. 4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.

HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.

NURSING HISTORY & PHYSICAL ASSESSMENT FORM

Student _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit _Oncology_BMH___ Instructor

Health History

Biographical Data:

Patient's Initials _______

Age _______  Gender _______ Martial status:  _______ DOB: _______

Birthplace: _______ Ethnic origin/Race: _______ Occupation: _______

Work status : _________ Educational background _______

History source initials _______ Relationship to client _______

Transcultural Considerations: (Time, space, touch, & value orientation, language considerations, spiritual beliefs, education level)

____________________________________________________________________________________________________

Special Needs:

____________________________________________________________________________________________________

Reasons for Seeking Care:

____________________________________________________________________________________________________

Past Health History:

____________________________________________________________________________________________________

Approximate hospitalization dates: _______

Serious or Chronic Illnesses (Approximate onset):
____________________________________________________________________________________________________

Obstetric Rotation

Current Obstetric Assessment:

Gravidity ______ Term ______ Preterm ______ Abortions ______ Living ______

Blood Type _____ Rh Factor _____

LMP _______ EDC _______ RhoGAM Status ______ DTR ________ (if applicable)

Date & Time of Delivery __________________________________

Type of Delivery ___ SVD ___ Forceps ____ Vacuum ____ Cesarean Section

___________ Anesthesia/Analgesia _______ EBL

Perineum: ______ Intact ______ Episiotomy _____ Laceration & Location__________________

Please note any current obstetrical problems/complications (GDM, pre-eclampsia, etc.)

Please note any past obstetrical problems/complications: (Condition, duration, treatment)

Infant Data:

Gender ______  Apgar Score ___ / ___ Gestational Age _____weeks Cord Vessels_____
Feeding method ______ Weight at Birth _______ Length at Birth ________

Blood Type & Rh ______ Direct Coombs ________ (if known)

Complications at Delivery:

Attachment Behaviors:

Allergies:
Medications:___________
What kind of reaction was experienced: ___________
Foods: ___________________________________________________________________
What kind of reaction was experienced:__________________________________________
Contact: __________________________________________________________________

What kind of reaction was experienced:__________________________________________

Current Home Medications: (all prescription, over the counter, home and herbal remedies, include trade or generic name, dose, and frequency) Reason for taking medication (patient stated).

1. Lisinopril 20 mg 1 tab q pm daily- lowers BP
2. Levothyroxine 100 mcg 1 tab qdsync daily- thyroid replacement
3. Ondansetron IV 4-8 mg q6hr or PRN- nausea med
4. Sennosides 8.6 mg 1 tab daily- for constipation
5. Polyethylene glycol 17 gr powder daily take with 8 oz of water- for constipation
6. Demecloclycline 300 mg 1 tab TID- tx of bacteria
7. Nystatin 5 mL QID swish and spit- tx of fungus
8. Insulin Reg (Human) PRN with sliding scale- for diabetes
9. Promethazine 12.5 +5mL q8hr dilute with 9mL NS prior to IV with max rate 25mg/min – helps with nausea and used for antihistamine
10. Hydromorphine brand: Dilaudid 2 mg q2hr or PRN- per pain

Substance use: (Frequency and amount)
Tobacco ____________
Alcohol  ____________

Illicit drugs ___________________________________________________________

Family History: (Health status or cause of death of blood relatives displayed in a genogram format)

Family & Social Support Systems:
Pt has a daughter and son that visit her daily. She also has a granddaughter that visits a few times.

Physical Assessment

Primary Medical Diagnosis:
__________________________________________________________________________

Secondary Medical Diagnoses:

__________________________________________________________________________
Height ________ Weight ________ Head Circumference (if < 2 yrs of age) _________________

Pain Score ______ Pain Goal ________ BMI ________ Oxygen Saturation ________

Supplemental Oxygen ________ Diet: ________Consumption ________

General Appearance:

__________________________________________________________________________

Patient's Health Promotion Activities At Home:
__________________________________________________________________________

Site Assessment of Invasive Lines and Drainage Tubes: (Note location, type, and findings)
__________________________________________________________________________

Mental Status - General Impression: (attach screening tool/results if used)

__________________________________________________________________________

Skin, Hair & Nails: Braden Scale Score: __________ (attached)

__________________________________________________________________________

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