RN PROGRAM CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN STUDENT NAME: PATIENT INITIALS: AGE: PAIN Assessment: Words

Intensity Location Duration Aggravating Alleviating factors Radiation HEIGHT: WEIGHT: HEAD CIRC: DATE: ALLERGIES: LMP:
GRAVIDA:

(mark n/a if not applicable)

PARA: AB:

PERCENTILE: PERCENTILE: RELIGION:

CHIEF COMPLAINT: (c/c) ( what brought the patient to Maryview originally) ex: fall, needed rehab

HISTORY OF PRESENT ILLNESS (The details involved in the chief complaint, when, where, how, what happen, how and why the patient came to reside at Maryview?)

PAST MEDICAL HISTORY(List of Medical Diagnoses) 1 TCD/10-07

CURRENT ORDERS DIET:

ACTIVITY:

TREATMENTS:

DEVELOPMENTAL ASSESSMENT PIAGETS STAGE: EVIDENCE: (what did you witness patient do for self today? Support your claim.) ERIKSONS STAGE:

EVIDENCE:

Date/ Time

Blood Pressure

Radial Pulse

Apical Pulse

Respiratory Rate

Oxygen Sat

Temp

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PHYSICAL ASSESSMENT
(Complete head to toe assessment. WNL is not accepted. Please be specific.)

Neurologic:

LOC: PERRLA: Orientation: Speech: Neck: Inspect Neck: Pain: Cranial nerve assessment:

Respiratory:

Chest symmetry, shape: Lung sounds: Tubes, O2 and SATs: Breast: shape:

Cardiovascular:

HR, rhythm: Apical pulse: VS TPR and BP: capillary refill: Auscultate heart sounds 1-5 points: Check for artificial devices: Peripheral Pulses:

Gastrointestinal:

Dentition: Abdomen appearance:

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Tubes: Bowel Sounds: Stool: last BM: occult blood: Ostomies: Genitourinary: Urethra drainage devises: Foleys: Urine: Vaginal area: Penis/Scrotum: Musculoskeletal: ROM: Peripheral Pulses: Muscle strength: Vertebral column: Mobile Devices:

Integumentary:

Skin: Hair: Nails:

Psychosocial:

Document Family dynamics: Behavior: Appearance: Pts Roles; Significant Relationships:

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Support Systems: What are pts Spiritual, Religious, and Cultural beliefs? Place Developmental Assessment in this area: Nutritional: Diet: Nutritional Supplements: Significant weight loss or gain in last 30 days:

MEDICATIONS Please include trade & generic name, dosage, action, reason your patient is receiving this medication, major side effects, and nursing implications.
Trade Name Generic Name Dose Route Trade Name Generic Name Dose Route Trade Name Generic Name Dose Route Trade Name Generic Name Dose 5 Drug Mechanism of Action (how does it work) Is Dose Appropriate ? PTs Weight TCD/10-07 Adverse Reactions Nursing Implications Drug Mechanism of Action (how does it work) Is Dose Appropriate ? PTs Weight Adverse Reactions Nursing Implications Drug Mechanism of Action (how does it work) Is Dose Appropriate ? PTs Weight Adverse Reactions Nursing Implications PTs Weight Drug Mechanism of Action (how does it work) Is Dose Appropriate ? Adverse Reactions Nursing Implications

Route Trade Name Generic Name Dose Route Drug Mechanism of Action (how does it work) Is Dose Appropriate ? PTs Weight Adverse Reactions Nursing Implications

LAB DATA & DIAGNOSTIC EVALUATION

Include date

LAB Ordered .

Client Values

Normal Values

Indication for Diseases / Illness

LAB Ordered

Client Values

Normal Values

Indication for Diseases / Illness

5 MEDICAL DIAGNOSIS MEDICAL DIAGNOSIS TEXTBOOK CLINICAL PICTURE

Definition, Signs, and Symptoms that should be seen, Citation

CLIENTS ACTUAL CLINICAL PICTURE

What Signs and Symptoms your patient actually exhibited

TCD/10-07

Top 3 PRIORITIZED Complete NURSING DIAGNOSIS: Remember ABC, Maslow! 1.

2.

3.

NURSING CARE PLAN

Student Name: ____________ Patient Initials: _______________ A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include related to, as evidenced by, or risk factors (if at risk diagnosis) for each medical diagnosis. Write at least one/ expected outcome measurable goal per nursing diagnosis stated in terms of client achievement - the client will). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal.
NURSING DIAGNOSIS
(NANDA APPROVED)

Date: ___

Class: ______

EXPECTED OUTCOME (Measurable Goal)

NURSING INTERVENTIONS (What do you plan to do?)

RATIONALE (Why are you doing this?)

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NANDA ND

1 Short term Goal

3 NSG Interventions

1 Rationale for each intervention.

Evaluate short term

1 Long term goal

Evaluate long term

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NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

NURSING DIAGNOSIS

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE

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10

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References
(APA format)

11

TCD/10-07