Florida Community College of Jacksonville

NUR 1022C: Nursing Care Plan for TERM 1

(rev 02/25/08)

Student Date of Care: Code Status

10/30/2010 Full
Client’s Initials Room # Age/Sex: 93 F Admit Date: 10/26/2010 Isolation Status Standard

Allergies NKDA Activity Level up w/ assistance Diet low cholesterol

Reason for Hospitalization Patient was eating breakfast @ asst. living facility when she dropped her fork and
became unresponsive to voice. Patient then made sound that resembled slurred speech. Patient was transported
to BMC -D ER. Were she then became responsive as if nothing had happened. Patient has no recollection of the
event.
Admitting Diagnosis Transient global amnesia, R/O TIA, SZ
TIA - transient ischemic shock, transient ischemic attack
SZ - Seizures
Other Medical Diagnoses – Pressure ulcer on R heel, R arterial ankle, R knee, L lateral ankle, L lateral foot all
unstaged.
Dementia

Previous Surgery /Year: ( last 5 yrs)

No known

Explanation of Admitting Diagnosis: (One-two sentences in own words about the pathophysiology; Then, 3-5 of the signs and symptoms of the
medical disease process) Memory disorder seen in middle aged and elderly persons characterized by an episode of
bewilderment and amnesia that lasts for several hours. The person is otherwise alert and intellectually active.
1. Patient was had sudden onset of memory loss that was verified by a witness.
2. Patient knew who she was and where she was after the incident
3. Memory loss was not longer than 24 hours
4. Patient had no signs indicating damage to a particular area of the brain such as limb paralysis, involuntary
movement or impaired word recognition
Vitals – temp. 98.3 HR 81 Res 19 BP 156/74 Pain (was not able to talk to patients but was told by ACP and RN
that patient is in a lot of pain. Does not like for anyone to touch her)

1
 MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Relief of mild to
Aspirin Safe Classification- Func. Class: Thrombocytopenia, Crushed or whole; chewable moderate
dose Nonopoid agranulocytosis, tablets may be chewed. discomfort.
(ASA) range: analgesic.NSAID,antipyretic,an leucopenia, Do not crush enteric coated
300-325 tiplatelet Chem. Class: neutropenia,hemolytic product. Increased ease
mg/d, 81 Salicylate. anemia, seizures, GI Take with food or milk to of joint
mg may bleeding, decrease gastric symp.; movement. May
be Action - Produce analgesia hepatitis,anaphylaxis, separate by 2 hr of enteric take 2–3 wk for
effective and reduce inflammation and laryngeal edema, N/V, product maximum
fever by inhibiting the rash. effectiveness.
production of prostaglandins.
Actual Decreases platelet
dose: Reduction of
aggregation. Therapeutic
81mg/PO/ fever.
Effects: Analgesia. Reduction
day of inflammation. Reduction of
fever. Decreased incidence of Prevention of
transient ischemic attacks and transient
MI. ischemic
attacks.
Indication: mild to mod. Pain
or fever including thromboletic Prevention of MI.
disorders; transient ischemic

2
 Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Classification: Antiplatelet Bleeding, neutropenia, Assess for symptoms of stroke, Prevention of
Safe agents thrombotic PVD or MI periodically during stroke, MI, and
clopidogrel
Dose: Platelet aggregation inhibitors thrombocytic purpura therapy and for thrombotic vascular death in
(Plavix)
300 mg thrombocytic purpura patients at risk
initially, Action: Inhibits platelet
then 75 aggregation by irreversibly
mg once inhibiting the binding of ATP to
daily; platelet receptors. Therapeutic
aspirin Effects: Decreased occurrence
75–325 of atherosclerotic events in
mg once patients at risk
daily
should be Indication Reduction of
given atherosclerotic events
concurren
tly.

Actual
dose: 75
mg/PO/Da
ily

3
 Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Bisacodyl Safe Classification: Laxative, Muscle weakness, Do not crush; monitor blood, Relief of gastric
Dose: 5– stimulant nausea, vomiting, urine electrolytes if used often; pain and
(Dulcolax 5mg tab) 15 anorexia, cramps, monitor cramping, rectal irritation
mL/dose Action: acts directly on tetany bleeding; give alone with water
up to 4 intestine by increasing motor for better absorption; do not
times/day activity take w/ in 1 hr of antacids
as liquid
or 2.5–7.5 Indication: decrease
mL/dose constipation
up to 4
times/day
as liquid
concentra
te
mg/dose
or 622–
1244
mg/dose
(2–4 tabs)
up to 4
times/day
.

Actual
dose:
5mg/ PO/
q12 h/
PRN

4
 Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Tums Safe Classification Arrhythmias, Observe patient for signs of Increase in
dose: T: mineral electrolyte constipation hypocalcemia )parasthesia, serum calcium
Calcium carbonate Preventio replacements supplements muscle twitching, cardiac levels.
n of Indication arrhythmias)
hypocalce Treatment/prevention of Decrease in the
mia, heartburn signs and
treatment symptoms of
of hypocalcemia.
depletion,
osteoporo
sis—1–2 Resolution of
g/day in indigestion.
3–4
divided Control of
doses. An hyperphosphate
tacid— mia in patients
0.5–1.5 g with renal failure
as
needed.
Hyperpho
sphatemi
a in end-
stage
renal
disease
—1 g with
each
meal,
increase
to 4–7 g
as
needed.

Actual
dose:
1000mg/P
O/Daily

5
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Safe C - mineral electrolyte Headache, tingling, doses with a full glass of water,
Increase in
Calcium Carbonate Dosage: replacements supplements arrhythmias, except when using calcium
Adult - 1– bradycardia, carbonate as a phosphate binder serum calcium
2 g/day in A - Replacement of calcium in constipation, nausea, in renal dialysis. Administer levels
3–4 deficiency states. Control of vomiting, calculi, Administer calcium carbonate 1– Decrease in the
divided hyperphosphatemia in end- hypercalciuria 1.5 hr after meals and at signs and
doses. stage renal disease without bedtime. Chewable tablets symptoms of
Antacid— promoting aluminum should be well chewed before
hypocalcemia
0.5–1.5 g absorption swallowing. Dissolve
as effervescent tablets in glass of Resolution of
needed. I - Treatment and prevention water. Follow oral on an empty indigestion
Hyperpho of hypocalcemia. Adjunct in stomach before meals to
sphatemi the prevention of optimize effectiveness in Control of
a in end- postmenopausal osteoporosis. patients with hyperphosphate
stage Relief of acid indigestion or hyperphosphatemia mia in patients
renal heartburn. Treatment of with renal failure
disease hyperphosphatemia in end-
—1 g with stage renal disease
each
meal,
increase
to 4–7 g
as
needed
Actual
dose:
100mg
PO Daily
(Y)

6
 MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C
Tylenol Extra Strength
1000mg q4h PRN (Y) A

7
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C - Therapeutic: CNS: headache, Monitor blood pressure and Decrease in
Norvasc Safe antihypertensives dizziness, pulse before therapy, during blood pressure.
dose: 5– Pharmacologic: calcium fatigue. CV: peripheral dose titration, and periodically
10 mg channel blockers edema, angina, during therapy. Monitor ECG Decrease in
once bradycardia, periodically during prolonged frequency and
daily; anti hypotension, therapy. severity of
hyperten A - Inhibits the transport of palpitations. GI: gingiv anginal attacks.
sive in calcium into myocardial and al hyperplasia, Monitor intake and output ratios
fragile or vascular smooth muscle cells, nausea. Derm: flushin and daily weight. Assess for
small resulting in inhibition of g. Decrease in need
signs of CHF (peripheral edema, for nitrate
patients excitation-contraction coupling rales/crackles, dyspnea, weight
or and subsequent therapy.
gain, jugular venous distention) .
patients contraction. Therapeutic
already Effects: Systemic vasodilation Increase in
receiving resulting in decreased blood Angina: Assess location, activity tolerance
other pressure. Coronary duration, intensity, and and sense of
antihyper vasodilation resulting in precipitating factors of patient’s well-being.
tensives decreased frequency and anginal pain.
—initiate severity of attacks of angina.
at 2.5 Lab Test
mg/day, Considerations: Total serum
↑ as I- calcium concentrations are not
required/t affected by calcium channel
olerated blockers.
(up to 10
mg/day)
as an
antihyper
tensive
therapy
with 2.5
mg/day in
patients
with
hepatic
insufficie
ncy

Actual
dose - .
5mg PO
Daily (Y) 8
 Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Colace Safe C – T – Laxative throat irritation, mild This medication does not A soft, formed
dose: P – Stool Softener cramps, rashes stimulate intestinal peristalsis. bowel
240 mg Administer with a full glass of movement,
daily A - Promotes incorporation of water or juice. May be usually within
water into stool, resulting in administered on an empty 24–48 hr.
Actual softer fecal mass. May also stomach for more rapid results. Therapy may
dose: promote electrolyte and water Oral solution may be diluted in take 3–5 days for
100mg secretion into the colon. milk or fruit juice to decrease results. Rectal
PO Daily Softening and passing of stool bitter taste. Do not administer dose forms
(Y) within 2 hr of other laxatives, produce results
I - PO: Prevention of especially mineral oil. May cause within 2–15 min
constipation (in patients who increased absorption
should avoid straining, such as
after MI or rectal surgery)
Rectal: Used as enema to
soften fecal impaction
Safe Classification: Seizures; hypotension; -Assess nutritional status and Increase in
Ferrous Sulfate Dose: Therapeutic- anti- anemic. nausea; constipation; dietary history to determine hemoglobin,
325mg Pharmacologic- iron dark stool; diarrhea; possible cause of anemia and improvement of
PO/ BID supplement epigastric pain; skin need for patient teaching iron deficiency
staining; anaphylaxis -Monitor BP and heart rate and anemia
Actual Action: Enters the bloodstream -Assess for signs and symptoms
Dose: and is transported to the of anaphylaxis
325mg organs of the Monitor hemoglobin, hematocrit
TID PO reticuloendothelial system
Daily (Y)
Iron Indication:
prevention/treatments of iron
deficiency

9
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Safe Classification: Tachycardia, Soduium Dose may be titrated rapidly Improved
Hydralazine (Isosorbide Dose: Therapeutic- vasodilators retention, drug- over 3-5 days, but may need to survival,
dinitrite) 1 tablet 3 Pharmacologic- vasodilators induced lupus decrease if side effects occur. increased time to
times nitrates syndrome, dizziness, May decrease to one-half tablet hospitalization
daily, headache, 3 times daily if intolerable side and decreased
may be Action: BiDil is a fixed-dose hypotension effects occur. Titrate up as soon symptoms of
increased combination of isosorbide as side effects subside heart failure in
to 2 dinitrate , a vasodilator with black patients
tablets 3 effects on both arteries and
times veins, and hydralazine , a
daily predominantly arterial
Actual vasodilator
Dose:
25mg PO I: Management of heart failure
q8h in black patients

MEDICATIONS (List 10-15 of the meds to be given from 0730 -1200)

Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Safe C: Hormones, thyroid Nervousness, Assess apical pulse and blood Resolution of
Levothyroxine dose: preparations headache, pressure. hypothyroidism
50mcg as arrhythmias, cramps, and
a single A: replacement of or hair loss, increased Assess for tachyarrhythmia’s normalization of
dose supplementation to sweating, and chest pain. thyroid hormone
initially, endogenous thyroid hormone. hyperthyroidism, heat levels.
usual The principal effect is intolerance
maintena Monitor thyroid function.
increasing metabolic rate.
nce dose Promotes gluconeogenesis.
75mcg- Increases utilization and Monitor blood and urine glucose
125mcg metabolization of glycogen in diabetics- may need to
daily. stores. increase insulin or oral
Actual hyperglycemic dose.
dose:
37.5 mg I: thyroid supplementation in
PO Daily hypothyroidism. Treatment
(Y) and suppression of euthyroid
goiters and thyroid cancer.

10
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
Safe C – Anti-anginal, anti- Fatigue, weakness, Monitor blood pressure, ECG, Decease in blood
Metoprolol Dose: hypertensive anxiety, depression, and pulse frequently during dose pressure.
50mg/PO/ dizziness, drowsiness, adjustment and periodically
BID A – Decreased blood pressure bronchospasm, during therapy. Reduction in
and heart rate. Decreased bradycardia, CHF frequency of
Actual frequency of angina. Monitor I&O ratio and daily angina attacks.
Dose: weights.
25mg PO I – Hypertension Increase in
BID Assess routinely for signs of CHF activity
(dyspnea, rales/crackles, weight tolerance.
gain, peripheral edema, JVD).
Prevention of MI
C - Therapeutic: analgesic CNS: dizziness, Conduct regular assessment of Reduction of
Ativan Safe adjuncts, antianxiety agents, drowsiness, lethargy, continued need for treatment. anxiety
Dose: sedative/hypnotics hangover, headache, Geri: Assess geriatric patients
1 mg Q6 Pharmacologic: ataxia, slurred speech, carefully for CNS reactions as
PRN IV benzodiazepines forgetfulness, they are more sensitive to these
confusion, mental effects. Ass falls risk.
Actual A - Depresses the CNS, depression, rhythmic Anxiety: Assess degree and
Dose: probably by potentiating myoclonic jerking in manifestations of anxiety and
0.5mg GABA, an inhibitory pre-term infants, mental status (orientation,
TID PRN neurotransmitter. paradoxical excitation. mood, behavior) prior to and
Therapeutic Effects: periodically throughout therapy.
Sedation. Decreased anxiety. EENT: blurred vision. Prolonged high-dose therapy
Decreased seizures. Resp: respiratory may lead to psychological or
depression. physical dependence. Restrict
I - Panic disorder, as an CV: rapid IV use only: amount of drug available to
adjunct with acute mania or Apnea, cardiac arrest, patient.
acute psychosis bradycardia, Status Epilepticus: Assess
hypotension. location, duration,
GI: constipation, characteristics, and frequency of
diarrhea, nausea, seizures. Institute seizure
vomiting, weight gain precautions.
(unusual). Lab Test Considerations:
Derm: rashes. Patients on high-dose therapy
Misc: physical should receive routine
dependence, evaluation of renal, hepatic, and
psychological hematologic function
dependence, tolerance

11
Generic Name (Trade Dose/ Classification, Action, & Major Side Effects Nursing Implications Evaluation /
Name) Route/ Indication for Client Effectiveness/
Time
C - antiemetic, 5-HT3 Headache, dizziness, Assess the patient for nausea, Prevention of
Ondansetron (Zofran) Safe antagonist drowsiness, vomiting, abdominal distention, nausea and
Dose: constipation, diarrhea, and bowel sounds. vomiting.
4mg IV A - blocks the effects of extrapyramidal
every 6 serotonin at 5-HT3-receptor reactions Assess the patient for
hours sites. extrapyramidal effects such as
PRN involuntary movements, facial
Actual I - Prevention of nausea and grimacing, trembling of hands.
Dose: vomiting
4mg q8h
PRN Check liver function test.

LAB/DIAGNOSTIC TESTS
Lab/Diagnostic Tests Purpose of Test Date and Results Implications for abnormals
List Normal Values for your Admission Most (why do you think your patient
had
hospital below Recent these abnormal values/what caused it
for this patient )
WBC assess WBC complete blood count 10, 000
(4,500-10,000 uL) (infection)
RBC Monitor RBC count
(4.6-6.0 mill/uL)
Hgb Level of hemoglobin in RBC 9.3 Low due to anemia.
(13.5- 18 g/dL)
Hct Volume of RBC in blood (dehydration) 27.5 Low due to anemia. Was given 1
(40-54 mL/dL)
unit of packed red blood cells
and fluids IV.
Platelets Check platelet count
(150,000-400,000 uL)

12
Glucose Glucose level to see if insulin is needed
(70-110 mg/dL) (hyper/hypoglycemia)
Na Monitor sodium levels
(135-145 mEq/L) (hyper/hyponatremia). Comparison of
sodium levels to other electrolyte
levels.
K Check Potassium level
(3.5-5.3 mEq/L) (hyper/hypokalemia)
Ca Check serum levels for 7.4 High due to patient taking
(4.5-5.5 mEq/L) hyper/hypocalcemia. Monitor calcium
Calcium suppliments
levels.
BUN Check renal disorder or dehydration
(5-25 mg/dL) associated with increased BUN levels
Creatinine Diagnostic tool for renal dysfunction
(0.5-1.5 mg/dL)
PT/INR Assess renal function 1.2 Low due to patient taking
(2.0-3.0 INR)
Coumadin prior to admittance
PTT Monitor heparin therapy and screen for 29.7 Low due to patient taking
(60-70 seconds) clotting factor deficiencies
Coumadin prior to admittance
WBC assess WBC complete blood count 10
(4,500-10,000 uL) (infection)
RBC Monitor RBC count
(4.6-6.0 mill/uL)
DIAGNOSTIC TESTS: Purpose of Test Date Results Implications for
X-rays, CT, MRI, US abnormals
12 lead EKG, ABG,
etc
X-rays Identify bone structure and tissue in
the body

CT Screen for CAD; head, liver, and renal

lesions; tumors; edema; abscesses;
infections; metastatic diseases;
vascular diseases; stroke; bone
destruction
MRI Detect a CNS lesion, vascular problem,
cardiac perfusion problem, injury,
tumor, edema.
US

13
 EKG Detect cardiac dysrhythmias. Identify
electrolyte imbalance. Monitor ECG
changes during stress/exercise tests
and recovery phase after a myocardial
infarction.
Detect metabolic acidosis/alkalosis, or
ABG respiratory acidosis/alkalosis. Monitor
blood gasses during an acute illness
and evaluate need for medical
intervention.

Nursing Diagnoses (PES Format)

1. Acute confusion r/t dementia AEB confusion and client yelling at healthcare providers when trying to provide care.__________

2. Impaired skin integrity R/T physical immobilization AEB pressure ulcer on R heel, R arterial ankle, R knee, L lateral ankle, L
lateral foot all unstaged_________

3. Risk for infection AEB numerous pressure ulcers

Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis

1. ___________________________________________________________________________________________________________

14
 Nursing Process

Nursing Diagnoses S=Supportive Data for Goals/Outcomes Nursing Orders & Scientific Basis for Client Responses/
P=Client Nursing Client Interventio Action/Rati
Problems Diagnosis Centered, ns onale Evaluation
(number in You must include: Stated in Include at least 5 specific
order of Subjective Behavioral interventions per Include source and page BE SPECIFIC!
priority) Objective Terms with problem. Asterisk (*) number for each
E=Pathophysiology/ Desired those interventions you intervention.
psychosocial Outcomes implemented.
(Must be specific and
measurable)

Acute confusion r/t Patient was eating Goal: Patient will *1. Assess the 1. Rapid onset and fl
dementia breakfast @ demonstr client’s uctuating
AEB asst. living ate behavior course are
confusion facility restoratio and hallmarks
an client when she n of cognition of delirium
yelling at dropped cognitive systemati (Inouye,
healthcare her fork status to cally and 2006).
providers and baseline continuall The CAM
when became y is
trying to unresponsiv Outcome: Patient throughou sensitive,
provide e to voice. will be alert and be t the day. specifi c,
care. Patient able to state place, (Ackley reliable,
then made time and persons. Ladwig. and easy
sound that Nursing to use.
resembled Outcome: Patient Diagnosis Another
slurred will demonstrate Handbook, tool to
speech. appropriate 247.) consider is
Patient was cognitive behavior *2. Note results of the MMSE
transported (Inouye,
all laboratory tests
to BMC -D 2006).
reporting
ER. Where 2. Laboratory results
abnormalities and
she then should be closely
follow-up with
became monitored and
primary care
responsive physiological
physician. (Ackley
as if support given as
15
 Ladwig. Nursing appropriate. (Ackley
nothing had Diagnosis Ladwig. Nursing
happened. Handbook, 248.) Diagnosis
Patient has *3. Conduct a Handbook, 248.)
no medication review.. 3. Medication use is
recollection (Ackley Ladwig. one of the most
of the Nursing Diagnosis important
event. Handbook, 248.) modifiable factors
84. Assess for and that can cause or
report possible worsen delirium,
physiological especially the use of
alterations (e.g., anticholinergics,
sepsis, benzodiazepines,
hypoglycemia, and hypnotics
hypoxia, hypo- (Inouye, 2006)
tension, infection, 4. Early attention to
changes in these risk factors
temperature, fluid may prevent
and electrolyte delirium or shorten
imbalance, and use the length of the
of medications with delirium episode
known cognitive and (Inouye, 2006).
psychotropic side 5. Lights and noise
effects). (Ackley can give rise to
Ladwig. Nursing agitation, especially
Diagnosis if misunderstood.
Handbook, 247.) Sensory overload or
*5. Modulate sensory deprivation
sensory exposure can result in
and establish a calm increased confusion
environment. Clients with a
(Ackley Ladwig. hyperactive form of
Nursing Diagnosis delirium often have
Handbook, 248.) increased irritability
and startle re-
sponses and may be
acutely sensitive to
light and sound.
Ackley Ladwig.
Nursing Diagnosis

16
 Handbook, 248.)

17
Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis
2.
___________________________________________________________________________________________________________

Nursing Process

Nursing Diagnoses S=Supportive Data for Goals/Outcomes Nursing Orders & Scientific Basis for Client Responses/
P=Client Nursing Client Interventio Action/Rati
Problems Diagnosis Centered, ns onale Evaluation
(number in You must include: Stated in Include at least 5 specific
order of Subjective Behavioral interventions per Include source and page BE SPECIFIC!
priority) Objective Terms with problem. Asterisk (*) number for each
E=Pathophysiology/ Desired those interventions you intervention.
psychosocial Outcomes implemented.
(Must be specific and
measurable)

18
19
Nursing Diagnoses (PES Format): P=Client Problems E=Pathophysiology/ psychosocial S=Supportive Data for Nursing Diagnosis
3.
___________________________________________________________________________________________________________

Nursing Process

Nursing Diagnoses S=Supportive Data for Goals/Outcomes Nursing Orders & Scientific Basis for Client Responses/
P=Client Nursing Client Interventio Action/Rati
Problems Diagnosis Centered, ns onale Evaluation
(number in You must include: Stated in Include at least 5 specific
order of Subjective Behavioral interventions per Include source and page BE SPECIFIC!
priority) Objective Terms with problem. Asterisk (*) number for each
E=Pathophysiology/ Desired those interventions you intervention.
psychosocial Outcomes implemented.
(Must be specific and
measurable)

20
21
 PHYSICAL ASSESSMENT
Circle and describe appropriate responses. If abnormal, describe within this assessment form
Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

Describe general appearance: (Physical appearance, Body structure, Mobility, Behavior)

Ht ________ Wt __________________ BMI_____________(Normal = 18.5-24.9)

BMI= weight (in pounds) divided by height (in inches)2 x 703
State of nutrition: Underweight____ Overweight____ Obese____ (>30)

PAIN Onset and duration:

Location (specify anatomical site):

Severity (use 0-10 pain scale):

Precipitating or aggravating factors:

Pain med given ? What med, dose, route? What time?

Effective? . No  Yes  (Describe how you can tell this)

NEURO Oriented to: time, person, place. Describe behavior if disoriented:

MENTAL
Any: Numbness, tingling, vertigo, syncope, headache, tremors, seizures, memory loss, aphasia/verbal behaviors, inattentive, agitation. No
STATUS
 Yes  Circle term &describe):

Cooperative: No  Yes  (describe):

Level of sedation (Glascow Coma Scale):

Best eye opening response?
Best motor response?
Best Verbal response?

22
 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

SKIN or Skin Temperature: warm, cool, dry, clammy,__________

WOUND
Skin characteristics: edema, blanching, cyanosis, pallor, jaundice, hyperemia, ecchymosis, petechiae, bleeding, cuts, boils, decubiti,
drainage, diaphoresis; rash, hematoma, nail changes.
Skin turgor/ Pinch test findings:

Describe hair color, condition & distribution:

Tattoos , piercings scars: Specific anatomical locations)

Wound Sites (Specific anatomical locations)

Dressings (Specific anatomical location , dressing composition, status):

Drains/Drainage (type and location):

EYES Vision loss, glasses, contact lens, excessive tearing, sty, exophthalmus, cataracts, artificial eye, ptosis, discharge
(describe)______________________________________ other: _______________________________
Test PERRLA ? No  Yes  Findings?
Test 6 Cardinal Positions of Gaze? No  Yes  Findings?
NOSE Rhinitis, epistaxis, loss of sense of smell, sneezing , discharge, irritation, other:_____________________
Septum midline: No  Yes  Nares patent: No  Yes 
EARS Deafness, hearing aid, discharge, tinnitus, other:_____________________
Whisper Test? No  Yes 
MOUTH, Dentures Bleeding gums, caries, implants, speech impediment, goiter, throat irritation, lesions; lips, gums, halitosis , Dysphagia,
THROAT Dysphasia, Tracheostomy, Hoarseness
& NECK Able to speak, bite, chew, swallow, taste; If any No, describe______
Lymph node enlargement? No  Yes (where)

23
 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

Uvula midline? Move anterior when says “ahh”? No  Yes 

Tongue thrust midline? No  Yes 

RESPIR Respirations: shallow, irregular, regular, irregular, other:____________

ATORY Nocturnal dyspnea, dyspnea on exertion, orthopnea unequal chest expansion, Tactile fremitus Cough: dry,
wet, productive, nonproductive; hemoptysis,
Lung sounds Anterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____;
Lung sounds Posterior chest RIGHT Clear ___ Diminished _____; LEFT Clear ___ Diminished _____; crackles ? _____ Where heard?
_________ wheezes? _____ Where heard? _________

Oxygen _____L/min Device: (type)______________________ Pulse Ox _________%

Incentive spirometer ______________ave._mL . Nebulizer ? _______ MDI? ______

CARDIO Heart Rate: apical_____ Rhythm: regular____ irregular___

VASCU Pulse deficit (Apical_____ minus radial______) PD________
LAR
Pulse Pressure: (Systolic)________minus Diastolic ______= PP______________
Peripheral pulses Present RIGHT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________
Peripheral pulses Present LEFT : Popliteal? _________ Post Tibial______ Dorsalis Pedis?___________

Edema: RIGHT pitting______ non-pitting_____ ; LEFT pitting______ non-pitting_____

Capillary refill_______ seconds; Lower extremity temp _________ and color: _________________

GAS Nausea, vomiting, dysphagia, anorexia, polydipsia, heartburn, ascites, constipation, diarrhea, abdominal distention, flatulence, tarry stool,
mucous stools, hemorrhoids, rectal bleeding, pain, incontinence, hernia, weight loss/gain
TRO-
INTES Date last B.M and characteristics: ___________________________________
TINAL
% of diet eaten: ____________________food intolerance ________________

Bowel sounds present RLQ? ________ RUQ?________ LUQ? ________ LLQ? ______________
NG tube_______ G tube_______ J tube_______ Ostomy_______

24
 Vital Signs @ Start of your care: Temp Pulse Resp BP
GEN-
ERAL
Vital Signs @ End of your care: Temp Pulse Resp BP

GENI Urine:color____________, clear, cloudy, Foley, Suprapubic catheter, CBI, dysuria, polyuria, oliguria, hematuria, nocturia, incontinence, flank
pain UTI, albuminuria, glucosuria, dribbling, hesitancy, frequency, burning, other
TO-
(specify)______________________________________________
URIN
ARY
Intake: previous 24 hrs. _________ During care: PO/Tube ____________cc IV_____________cc

Output: previous 24 hrs. ________ During care:urine________________CC other`(specify) ______

MUS Joint pain, arthritis, gout, claudication, varicose veins, paralysis, contractures, deformities, amputations, unsteady gait.
CULO- Describe ROM and strength in each extremity (0-5 scale):
SKE Head & Neck____; R arm_________; L arm_______; R leg__________; L leg____________
LETAL
Describe activity tolerance:

Describe ability to ambulate/ gait:

IV/ IV site(s) ____________________________ -__________________________________

INFUS
IV type(s)_______________________Rate_____ ; _______________________________ Rate _____
ION &
CATH IV needle gauge?______ Date inserted: __________ Site condition: ___________________________
ETERS
Tubing change date: ______________ IV Site care given: No  Yes 

THERA Walker, crutches, cane, trapeze, prosthesis, wheelchair, scooter, CPM,SCDs, TEDs, Heating pad, Ice pack, bed fall monitor, therapeutic
PEUTIC
bed, wound VACs, PCA pump, cooling/heating blanket,
Or
ASSISTIVE Implants: ___________________________________________________
DEVICES

DOCUMENTATION (Your Nurses Notes defining care given)

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References

Ackley, B. J. & Ladwig, G. B. (2006). Nursing diagnosis handbook. 8th ed. St. Louis, MO: Mosby.

Deglin, J. & Vallerand, A. (2009). Davis’s drug guide for nurses. (11th ed.). Philadelphia: Davis.

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