PATIENT INFORMATION:
PT Initial: _ Age Gender Race/Ethnicity _ Primary Language _ Religious Affiliation __
Date of Admission: Admit Reason/Symptoms: _______________________________¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬-_____________________________
Current Medical Diagnosis: ______________________________________________________________________________________________________
Current surgeries or procedures (Planned or performed with date): _______________________________________________________
Past Medical History (Resolved Medical Diagnoses/Illnesses/Surgeries, give date): ______________________________________
Family (Genetic) History of Diseases: __________________________________________________________________________________________
Educational Level: ___ Living Arrangement: _______________________________________________________________________
Discharge Plan and educational needs (Parent/Child): _______________________________________________________________________
Allergies & Reaction: _____________________________________________________________________________________________________________
Precautions (circle) confusion, suicide, paralysis, infant or toddler, fall risk, other: _______________________________________
Advance Directives (Do Not Resuscitate/Other): Yes _ No Comments: _______________________________________________
DAY OF CARE:
All current MD orders for day of care: __________________________________________________________________________________________
Respiratory Care: ________________________________________________________________________________________________________________
Dietary Orders: ___________________________________________________________________________________________________________________
Diagnostic studies treatment for day of care (x-ray, ultrasound, CT, etc.): __________________________________________________
Prioritize activities for nursing care for your shift (respiratory care, vital signs, feeding, hygiene, meds, assessment, therapy, education, play, ect.)
- 4.
- 5.
- 6.
PATHOPHYSIOLOGY:
Provide a definition of TWO problems: pathophysiology, etiology, epidemiology. Include signs and symptoms of the disease, relevant laboratory studies with indication of values if high or low (blood, or other body fluid tests); diagnostic studies (x-rays, ultrasound, electrocardiograms, etc). Identify the interventions (surgical procedures, interventional procedures, types of medications, etc.) used to treat/cure this disease or illness. Describe the complications that can develop from this disease/illness. List specific nursing interventions provided to treat this disease/illness or to prevent complications from this disease/illness. Identify whether this is an ACUTE ILLNESS; CHRONIC; TERMINAL.
All may not apply to your patient. Highlight what specifically applies to your patient.
APA References:
Develop a comprehensive list of expected developmental milestones for a child who is your patient’s age. Then list developmental milestones your patient has achieved.
Patient’s Age______ Expected Developmental Milestones My Patient’s Milestones
Cognitive:
Social:
Physical:
Gross/fine motor:
Discuss the expected developmental level according to the following theorists. Then discuss where your patient
Patient’s Age __ Expected Actual
Erikson (psychological)
Piaget (cognitvie)
Freud (psychosexual)
APA References:
Prioritize top 6 Nursing Diagnoses (List must include a minimum of one wellness diagnosis.)
Nursing Diagnosis Rationale for Selection
Priority from Nursing Diagnosis Prioritization and NANDA Diagnostic Statement
Nursing Outcome Desired During Your Shift (NOC)
Nursing Activities:
List 3, at least one must be hands on. List who will perform. (NIC)
Rationale for Each of Your Nursing Activities.
Use References.
Based on NOC Outcome Criteria, Evaluate Nsg Activities. Goals
If not met, what will you change?
Priority #1:
NANDA Statement:
NOC Outcome:
Patient Goals:
Measurement Criteria:
NIC:
1.
2.
3.
Rationales:
1.
2.
3.
APA References:
Goal was: (circle one)
Met Not Met
Partially Met (explain):
Evaluation of Nursing Activities:
Based on measurement criteria:
What was happening with your patient?
What will you change?
(priority, goal, activities)
Priority from Nursing Diagnosis Prioritization, and NANDA Diagnostic Statement Nursing Outcome Desired During Your Shift (NOC) Nursing Activities:
List 3, at least one must be hands on. List who will perform. (NIC) Rationale for Each of Your Nursing Activities.
Use References. Based on NOC Outcome Criteria, Evaluate Nsg Activities. Goals
If not met, what will you change?
Priority #2:
NANDA Statement:
NOC Outcome:
Patient Goals:
Measurement Criteria:
NIC:
1.
2.
3.
Rationales:
1.
2.
3.
APA References:
Goal was: (circle one)
Met Not Met
Partially Met (explain):
Evaluation of Nursing Activities:
Based on measurement criteria:
What was happening with your patient?
What will you change?
(priority, goal, activities)
Care Plan Checklist
_ Completed Care Plan Medication Chart
Growth Charts Vaccine record
Recent Lab results _ Daily Charting from date of care
Sample Solution
