NR 341
Student Name: __________________________________________ Day/Date: _______________________________________
NR 341 Patient Centered
... [Show More] Clinical Care Packet: Plan 2
DATA COLLECTION SHEET
Patient Initials: L.F. Room # 203 DOB: 1/12/1963 Age: 52 Gender: Female Date admitted 1/25/2017
Admitted to facility Date: 1/25/2017 Resuscitation Status: Full Code
Allergies: No Known Allergies Reaction: N/A
Reason for Admission: Pt. was found down in a park with a large Right forehead laceration and no witnesses as to what happened to her, or why she may have originally passed out. Patient was unresponsive, combative and in an altered state of consciousness.
Medical diagnoses r/t this admission: Right forehead laceration, unprotected airway due to current state of consciousness, her GCS was a 9 on admit.
Is patient aware of all dx? During ventilation vacation, patient became aware of her diagnosis. She is aware of her own drug and alcohol abuse history.
Other medical, psychological, psychiatric diagnoses: ETOH Abuse, Narcotic abuse
Health condition prior to this admission: Fair to poor, due to substance abuse, but no other diagnosis have been made.
Past and current surgeries/procedures and dates: Unknown due to ventilated status.
Medications presently taken at home and why? Unknown.
Use of prescribed/complementary medications: N/A
Environmental/ambulation aids used (glasses, hearing aid, cane, brace, w/c, ramps): N/A
Social: Single Significant other, Next of Kin or POA for Health Care: Sister is next of Kin but has no power of attorney.
Occupation or former occupation: Unemployed, lives in a half way house.
Financial challenges: Uninsured
Housing: Lives in a halfway house, try to become sober.
Religion/considerations? None
Culture/considerations? None
Presence of family, supportive individuals/relationships: Sister was contacted and is now at bedside.
Plan for care after discharge (home, transitional care, SNF, home care) The patient will likely be discharged and enter into a rehab facility with the help of her sister so that she is able to be successful with her sober living. At this point however, she needs to prove that she will be able to breathe off the machine and that she has the appropriate level of cognitive mental function after her injury.
Current Physician/Health Care Provider Orders (Prescriptions for Care)
ITEM TYPE THIS PATIENT’S ORDERS “WHY” FOR THIS PATIENT? EXPLAIN
Diet (when ate last? TPN, restrictions?) NPO Patient is intubated and has an altered state of consciousness, she will eat upon extubation
Activity-incl ROM Active Range of Motion, Q2 turns while under sedation Patient is intubated however she moves upon demand and follows commands.
Intake & Output
VS frequency-how performed and verified Q hour, performed automatically, BP cuff remains on.
Alarm settings Bed alarm
Blood glucose monitoring N/A
Foley catheter/straight cath/suprapubic Foley catheter- 16 french
Nasogastric-type, size N/A
Colostomy/ileostomy N/A
PEG/PEJ tube N/A
Wound Care /
Dressing Change/location Bacitracin over sutures at the end of each dressing change.
Respiratory Treatments (vent, ABGs, inhaler, O2) Ventilator, ETT, Cuffed, 7.0 oral, Subglottic/CPAP
If ventilator-orders for oral care? Oral care q 2 hours while vented
Tracheostomy N/A
Suctioning-frequency, size) PRN, in-line
Chest Tube-location N/A
Special Equipment N/A
Lab orders Electrolytes and lactulose
Other
Rehab Services Activity or Treatment Plan & Schedule Rationale-why ordered for this pt? What progress is seen or expected to be the goal for this patient?
Physical Therapy ROM exercises
Speech Therapy Will conduct assessment
Occupational Therapy No orders yet.
IV Access: date inserted
Type and size for each line Peripheral IV 20 gauge Right AC, Peripheral IV 20 gauge Left AC.
Last Dressing Change-type of dressing in place Head Dressing changed 0918- steristrips
Reason for IV access-why additional site present? Additional access is necessary in case something infiltrates or becomes inaccessible for any reason, also in case you need to give two meds that may not be compatible you have the access you need.
IV fluids and meds (complete IV therapy sheet)
Central line access: type/why What signs would tell you there is a problem? What are you looking for?
.45 Normal Saline
No Central Line access on this patient.
Most recent Imaging Findings: (CXR? CT? MRI?)
Type of Imaging (X-Ray, CT, MRI, etc). WHY ORDERED FOR THIS PATIENT? Body Area Imaged What nursing care is needed before, during, or after the test? (i.e., NPO except H2O? hold Glucophage?)
CT Maxiofacial Ordered for this patient due to fall/laceration to rule out any internal bleeds or issues.
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date done Lab Test Results Previous day result? Trend? NORMAL VALUE for this patient? (age, sex, etc) Comments—what is the significance of this result? WHAT DOES IT MEAN FOR THIS PATIENT?-
1/25 ETOH 323 0 This means she had a large amount of alcohol in her system
Lactulose 2.4 0.5-2 This mean the patient could be getting septic
Benzos Positive Negative This means she has been using benzo products
CK 312 21-215 Her kidneys are working harder than they should.
Sodium 134 135-145 Needs to be replaced or she could start having more kidney issues, maybe this is why…
Potassium 3.4 3.5-4.5 Needs to be replaced this shift to prevent any heart issues.
HCG Undetermined Negative Her pregnancy screening needs to be run again.
Other recent, significant procedures or tests (EKG, cardiac stress test)
Date Test Reason for testing and results of test; Significance of this result for this patient?
Nursing care before or after this procedure/test?
The following head-to-toe assessment is what students are required to perform on all patients. Specialty assessments will be based on course and course instructor.
Assess level of consciousness (LOC), orientation to person, place, and time, mood, affect, developmental level, level of assistance required for ADL’s
T-P-R B/P, pain level (0-10 scale) & location, pulse oximetry
1. Assess the head:
a. General survey for gross abnormalities, symmetry of face.
b. Color of sclera, conjunctiva dryness of eyes or presence of drainage/discoloration
c. PERRLA
d. Oral cavity: odor, lips, teeth, gums, buccal cavity, tongue protrudes midline, swallowing
e. Presence of hearing aids and/or glasses
Throughout assessment continually observe and note condition of hair, skin (turgor), and nails. Provide ongoing monitoring of skin condition including Braden Scale
2. Assess and compare bilateral upper extremities for:
a. Hand grasps for equality and muscle strength
b. Temperature and color
c. Brachial & Radial pulses
d. Capillary refill
3. Assess apical pulse:
a. Auscultate heart sounds (S1, S2) at five valve points including point of maximal intensity (PMI)
b. Listen for one minute, noting rate, rhythm, and regularity
4. Assess lungs
a. Observe rise and fall of chest: assess for chest expansion & use of accessory muscles (retractions)
b. Auscultate breath sounds
i. Assess anterior chest in 4 sites and 2 lateral sites
ii. Assess posterior chest in 6 sites and 2 lateral sites
5. Assess abdomen
Inspect abdomen for contour, lesions, scars
b. Auscultate bowel sounds in all four quadrants
c. Palpate abdomen for firmness, tenderness, and suprapubic region for bladder distention
d. Assess last BM and consistency
e. Assess urinary output (color, odor, amount)
6. Assess and compare bilateral lower extremities for (CMS):
a. Movement and muscle strength (ankle push), sensation, capillary refill
b. Temperature and color, hair distribution
c. Dorsalis pedis (pedal) and posterior tibial pulses
d. Assess for DVT, swelling, measurements
e. Edema (generalized vs pitting)
7. Monitor diet and nutritional intake
8. Check equipment:
a. IV Solution, rate, assess site for s/s inflammation and infection
b. O2 Setting and device, assess skin
c. Drains (including urinary catheter, feeding tubes, chest tubes, penrose drains, etc.)
9. Survey environment for safety concerns-ongoing, fall risk
At completion, place call light within reach, put bed in low position, return table and supplies at reachable distance, and assure pt. is comfortable and safe. Wash hands after removing gloves that may have been used.
Additional information:
• The student will report any abnormal findings to RN and instructor immediately.
• The instructor will observe an assessment on a patient a minimum of once/clinical rotation with feedback provided to the student.
• A full assessment will be performed on the patient unless the situation or patient’s condition precludes the event.
• A manual blood pressure rather than electronic will be performed when possible.
Use this sheet for jotting down your assessment findings. Follow guidelines from NR302/NR304 head-to-chest sheet.
Routine Findings Patient Variations/Abnormal
Skin: Warm, dry, no blanching over bony prominences Right and Left anterior leg abrasions from falling.
Head and neck:
Neck is supple, no JVD is present, no gross abnormalities, face is symmetrical.
No facial Fx, per CT, no C-Spine deformities, collar is in position.
Respiratory: Lung sounds are clear and equal, slightly diminished at the bases. No use of accessory muscles.
Intubated due to GCS of 9
Cardiovascular
Cardiac: Heart sounds at S1 & S2 and at all five valve points. Pulses +2. Rate is Sinus Rhythm at 86
Gastrointestinal:
Bowel sounds present in all four quadrants, Abdomen is soft, no masses rebounded tenderness or rigidity
Bowel continence? Last BM?
Bowel Plan?
Neurological :
Alert and Oriented When sedation is off, pt. is alert and oriented x3
Musculoskeletal:
Bilateral upper and lower extremities within normal limits with range of motion.
Genitourinary:
Foley catheter in place, plans to D/C with extubation, good output. Urinary continence?
Toileting plan?
Nutritional assessment: Malnutrition due to lifestyle Deferred?
Rectal: no sores, tone present
Pelvis: Stable, no compression Deferred?
After analyzing the patient’s assessment findings, what diagnosis is having the greatest impact on today?
The DX with the greatest impact on today would have to be the fact that she is intubated. She had to be intubated to protect her airway; however, because her CT shows no other damage to her head and she is alert and oriented when she is not sedated, the HCP is getting ready to extubate her. This is necessary so that she does not develop VAP and can begin to breathe on her own again.
Describe the pathophysiological changes in the body for the disease/disorder that is the reason for admission—what is happening? (cite reference on reference page)
The number of people with Traumatic Brain Injury (TBI) is difficult to assess accurately but is much larger than most people would expect. According to the CDC (United States Centers for Disease Control and Prevention), there are approximately 1.5 million people in the U.S. who suffer from a traumatic brain injury each year. 50,000 people die from TBI each year and 85,000 people suffer long term disabilities. In the U.S., more than 5.3 million people live with disabilities caused by TBI. Patients admitted to a hospital for TBI are included in this count, while those treated in an emergency room or doctor’s office are not counted.
Describe the expected textbook signs and symptoms seen in this patient:
Loss of consciousness, compromised airway due to GCS of 9, bleeding due to head laceration.
What are factors in the patient that may affect the symptoms that are present, or why symptoms are different or not observed?
The factors in this patient that may affect her are her decision to drink at the levels she does. This is ultimately what caused her to fall and hit her head and cause her to lose consciousness. If she were to get sober and make better life decisions, this sort of thing would not be likely to happen again.
What stage from Erikson fits your patient? What is your patient’s response to the opportunities and potential conflicts of this stage based on illness?
He is in the stage of generativity vs. stagnation at the age of 56. His conflict is his approaching of older age, not having made the kind of financial gain he wishes (according to his wife) and having feelings of frustration with where his life landed him thus far. The conflict he faced was whether or not he should just live the life he wanted to by smoking, drinking and living without medication to manage his health because maybe he knew he would never gain the financial freedom he sought out for his family and an early death was easier based on previous family history.
3 minimum, 9 maximum (including prns)
You may copy and paste these tables onto the next sheet if you have more medications
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Lorazepam
Ativan
1-2mg Allergies to benzos, narrow-angle glaucoma, or myasthenia gravis
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Benzodiazepine
1mg= .5ml Drowsiness, SI’s, confusion, sleep problems
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Used to treat alcohol withdrawal symptoms
IV Push
Q1 hour PRN This medication can cause addiction, it is to be used cautiously and should not ever be taken with alcohol.
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Fentanyl Infusion
(Sublimaze)
Varies widely
Uncontrolled respiratory depression
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Opioid/narcotic
50-250mcg/hr
25 every hour Weak breathing, severe weakness, stiff muscles, allergic reaction, light-headedness, fainting
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Pain related to diagnosis
IVP
Q 1 hour Do not operate heavy machinery while on this medication,
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Propofol
(Diprivan)
5mcg/kg/min may increase every 5 minutes to desired level of sedation. Skin rash or other signs of hypersensitivity
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Paralytic 5mcg/kg/min Drowsiness, dizziness for several hours, itching or rash, fast or slow heart rate, burning at injected site.
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
Ventilated Intubation
IVPB
infusion Propofol is used to help you relax while the patient is connected to a mechanical ventilator.
Brand Name and Generic Name Normal Dosage Ranges Contraindications
Pharmacotherapeutic Class Dosage Ordered Adverse Reactions
Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching
INTRAVENOUS THERAPY including Blood Products
DATE and TIME:
Assessment of site of infusion:
Site, gauge, without S&S pain/ swelling/ redness/ frequency of assessment IV solution: include additives, medication, frequency, route to be given
Infusion by:
Gravity, pump
(Calculate volume and ml/hr) Why is this patient receiving this IV therapy? Nursing considerations before administering. What life threatening/ most common reactions to monitor/observe
*Compatibility Evaluation of patient’s response
Expected response?
Actual response?
20 Gauge A/C Right side
No swelling, or redness. 0.9% NS 80ml/hr Maintenance Fluids Hypovolemia Adequate hydration
Show calculation of ml/hour and volume to be infused.
Dose: 80 ml/hour in 1000ml bag of 0.9% NS
For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. See samples of assessments on the next page. Take the “Physical Assessment Worksheet” into the patient’s room to take notes during your assessment.
Date / Time Physical Assessment findings (Head-to-Chest Assessment) and nursing care that you provided.
(IF Labor and Delivery: include Fetal Heart Rate assessment on a line below vital signs—assessing maternal-fetal unit)
TEMP Apical HR Respiratory BP Pulse oximetry Pain scale
Rate Arm: (manual or and describe pain
(Verified with stethoscope?) electronic?)
Peds: (Leg?)
1/26 0810 37.3 83 17 156/86 98
Pain was assessed by watching for grimacing, heart rate, increasing blood pressure XXXXXXXXXXXXX
1018 36.5 78 12 155/91 100
1130 37.2 68 12 151/88 100
During sedation vacation, patient is alert and oriented x3, recent memory is not completely intact
But remote memory is intact. No weakness or paralysis, no abnormal posturing or involuntary
movements. Skin is pink, warm, dry and free of lesions, only skin lacerations are on the left and right
Anterior legs from falling. Pupils are equal and reactive to light. Oral mucosa moist and pink,
Lung fields are clear bi-laterally, respirations are non-labored on the ventilator without use of
Accessory muscles. Apical pulse regular rate and rhythm. Capillary refill < 3 seconds. XXXXXXXXXXXX
12/22/2015 1400 98.6, 72, 16, 128/62 (L arm), 94%, Pain 3/10
0815: Alert and oriented x 3. Recent and remote memory intact. Motor and sensory functions grossly intact. No weakness or paralysis. No involuntary movement or abnormal posture. Denies dizziness upon ambulation. States “had a great night sleep”. Pain score 3/10 due to deep ache in left ankle at surgical site. States “felt better when raised up on pillow in bed”. Appropriate mood and affect. Wants to sit in chair to eat breakfast and dinner every day. Skin pink, warm, dry, free of lesions. Elastic turgor. Hair and nails unremarkable. Pupils equal, reactive to light and accommodation. Oral mucosa moist, pink. Dentition intact. States has not brushed teeth since before surgery. Oropharynx clear without erythema or exudate. Lung fields clear bilaterally to auscultation. Respirations non-labored without retractions. Denies cough and dyspnea. Apical pulse regular rate and rhythm. Carotid, radial, and pedal pulses palpable and equal bilaterally. Capillary refill < 3 sec. Assisted with use of bedpan-350 cc light yellow clear urine prior to completion of assessment.------------------------------------------------------------Toni Cox, Chamberlain Student Nurse
NR341 Complex Adult Health Addendum
Copy a sample from the Internet showing the patient’s rhythm:
Regular Sinus Rhythm
Interpretation: (Rhythm, What is happening in the heart, what is the result in the body due to this rhythm? What is the danger? What is the treatment?)
In a normal heart rhythm, the sinus node generates an electrical impulse which travels through the right and left atrial muscles producing electrical changes which is represented on the electrocardiogram (ECG) by the p-wave. The electrical impulse then continue to travel through specialized tissue known as the atrioventricular node, which conducts electricity at a slower pace. This will create a pause (PR interval) before the ventricles are stimulated. This pause is helpful since it allows blood to be emptied into the ventricles from the atria prior to ventricular contraction to propel blood out into the body. The ventricular contraction is represented electrically on the ECG by the QRS complex of waves. This is followed by the T-wave which represents the electrical changes in the ventricles as they are relaxing. The cardiac cycle after a short pause repeats itself, and so on.
Guidelines for Patient Assessment and Plan of Care
• A complete care plan is one that contains 3 (three) complete 3-part Nursing Diagnosis, desired
patient outcomes and nursing interventions.
• In text citations and references must be in APA format.
• The following are not to be used: “WNL”; “N/A”; “no problems”; “did not assess”
• Use appropriate medical terminology.
• See grading rubric for additional details.
• Follow instructions as provided in individual courses.
Student name: Lindsey Isaacs Course: Critical Care Clinical instructor name: Aimee Kollat Date of Patient Care: 1/26/2017
Patient Initials, Age, Gender: L.F 52 yo Female SUBJECTIVE DATA: OBJECTIVE DATA:
#1 PRIORITY NANDA NURSING DIAGNOSIS: Ineffective Airway Clearance related to decreased respiratory muscle function as evidenced by Glasgow coma score.
Related to (causative factor): unresponsive to stimulus upon arrival to hospital, O2 sats upon arrival were insufficient for effective airway protection.
As Evidenced By (CLUSTERED SIGNS AND SYMPTOMS [DATA]
poor neurologic function leading to inability to breath on his own.
Desired Patient Outcomes (GOALS)
Make sure they are S.M.A.R.T. goals and have a time frame stated PRIORITY Nursing Interventions
Make sure they are S.M.A.R.T. interventions and have a time frame stated. Rationale for interventions
(APA citations) Observation of Results of intervention
Evaluation of plan
Can goal be met? Why/why not? What change in plan may be needed?
Patient will:
Maintain an open airway during admission to the ICU
Patient will:
Maintain a normal respiratory rate and normal percentage of oxygen saturation.
1) Assess airway for patency, auscultate for wheezing, or crackles.
Rationale: wheezing can indicate partial airway obstruction, Crackles indicate fluid in the alveoli (Lewis 2014).
Observation: Airway remains patent and ET tube remains in place throughout shift.
2) Monitor oxygenation saturation and assess arterial blood gases
Rationale: Decreased partial pressure of oxygen and decreasing oxygen saturation can result from excessive airway secretions.
Observation: Oxygenation saturation maintains between 94 and 99% during intubation.
3) As long as patient remains on ventilator, monitor peak airway pressures and airway resistance.
Rationale: Increased airway pressure and resistance indicates excessive secretions and inadequate ventilation.
Observations: On the Ventilator, through my shift, peak pressure and airway resistance remain within appropriate levels.
Student name: Lindsey Isaacs Course: Critical Care Clinical instructor name: Aimee Kollat Date of Patient Care: 1-26-2017
Patient Initials, Age, Gender: L.F. 52 yo female SUBJECTIVE DATA: OBJECTIVE DATA:
#1 PRIORITY NANDA NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements, related to refusal to eat prior to hospitalization, as evidenced by patient not maintaining a stable weight.
Related to (causative factor): drug and alcohol use, unemployment.
As Evidenced By (CLUSTERED SIGNS AND SYMPTOMS [DATA]
BMI does not meet requirements for height.
Desired Patient Outcomes (GOALS)
Make sure they are S.M.A.R.T. goals and have a time frame stated PRIORITY Nursing Interventions
Make sure they are S.M.A.R.T. interventions and have a time frame stated. Rationale for interventions
(APA citations) Observation of Results of intervention
Evaluation of plan
Can goal be met? Why/why not? What change in plan may be needed?
Patient will:
Prior to discharge from the hospital patient will relay an understanding of the importance of quality nutrition for her bodies daily needs.
Patient will:
Patient will weight within 10% of her ideal body weight prior to discharge.
Obtain a nutritional history on the patient. Family members may be more likely to provide a more accurate estimate of the patients eating habits (Lewis 2014). Patient and her Family provide a good overall picture of her nutrition history, which allows hospital staff to collaborate and plan. Plan may not be met if family was not around her or was not able to help provide this type of history.
Consult a dietician for nutritional recommendations and resources. A dietician can measure nitrogen balance to assess the patients nutritional status. Dietician is able to run labs and fully assess problem areas of the patients diet and make recommendations. This plan is easily achievable.
Establish nutritional goals. Improvement in nutritional status requires several months. Short term goals allow for provision of reward early in the treatment. Nutritional goals are set and small goals are achievable and the patient begins to work toward them. This plan can only come in to play if the patient is willing to listen and understand the importance of changing her nutritional status.
Student name: Lindsey Isaacs Course: Critical Care Clinical instructor name: Aimee Kollat Date of Patient Care: 1-26-2017
Patient Initials, Age, Gender: L.F 52 yo Female SUBJECTIVE DATA: OBJECTIVE DATA:
#1 PRIORITY NANDA NURSING DIAGNOSIS: Risk for infection related to inadequate primary defenses caused by head laceration.
As Evidenced By (CLUSTERED SIGNS AND SYMPTOMS [DATA] Symptoms of infection
Desired Patient Outcomes (GOALS)
Make sure they are S.M.A.R.T. goals and have a time frame stated PRIORITY Nursing Interventions
Make sure they are S.M.A.R.T. interventions and have a time frame stated. Rationale for interventions
(APA citations) Observation of Results of intervention
Evaluation of plan
Can goal be met? Why/why not? What change in plan may be needed?
Patient will:
Patient will have an improving level of consciousness and absence of furthered confusion.
Patient will:
Patients will state knowledge and overall understanding about signs and symptoms of infection and what to do if something comes up.
Clean and cover scalp wound with sterile dressing Clear or bloody drainage from the nose, throat, or ears may result from a dural tear with CSF leakage and the physician should be notified (Lewis 2014). Keeping the wound clean and covered keeps the wound from being exposed to more possibility of infection.
This plan can be easily met while the patient is in the hospital setting.
Place patient in semi-fowlers position. This position reduces cerebral edema and increases venous drainage. Patient is put in the semi-fowlers position, this is an easy intervention with a good amount of benefit for prevention of infection. This plan can be easily met.
Assess injury site for signs of infection. Erythema, pain and purulent drainage are signs of infection and should be assessed regularly. Regular assessment of the injury site leads to prevention of further complications from infection. This plan can be easily met
RUBRIC: Student: Lindsey Isaacs Clinical Date: January 19, 2017 Site: Banner University Medical Center
Section Grading Criteria
U
NI
S
E
Comments/Recommendations for the future Comments, Kudos,
Things to Improve for Next Time
Patient Data Collection • Patient Demographics, Diagnoses, Surgeries, Orders, therapies, IV, Imaging and Lab are fully and correctly completed
• Developmental stage & potential conflict correctly identified
• Prioritized care identified & appropriate
• Used appropriate resources
Medication Preparedness
• Medication Trade & Generic name, Pharmacological Classification, Normal Dosage Range, dose ordered, route & frequency, contraindications & Adverse Effects/Reactions identified appropriately
• Nursing Considerations & Teaching appropriate for this patient
• Legibly written or typed clearly
Assessment
• Head-to-toe assessment performed and documented clearly and accurately
• Nurses Note is in logical order, using appropriate language & clearly understood.
• Abnormal findings have a follow up note
Patient Care Plan
Nursing plan of care completed
• Total of three appropriate Nursing Diagnosis (ND) or Collaborative Problems (CP) identified.
• ND or CP properly formatted with “Related to” statement correctly formatted and appropriate for this patient.
• “As evidenced by” is appropriately stated and correct for this patient
• Outcomes specific, measurable, timed
• Interventions are logical and appropriate for this patient
• APA reference for 1st intervention of each Nursing Diagnosis; support the rationale
Total points possible/Total points earned DATE and TIME REVIEWED WITH STUDENT
REFERENCES:
1) Lewis, Sharon, Dirksen, S., Heitkemper, M., Bucher, L. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 9th Edition. [VitalSource Bookshelf Online]. Retrieved fromhttps://online.vitalsource.com/#/books/9780323086783/
2) http://www.traumaticbraininjury.com/understanding-tbi/what-are-the-causes-of-tbi/
Based on the information on these pages and your assessment of this patient, what were you most
concerned about?
What actions were done to promote safety for this patient that was individualized specifically for
your patient and why?
Describe the differences between what you heard in report and what you found when you provided care for the client?
Describe something that you felt “unprepared for”. What would have helped you be prepared?
What did you learn by taking care of this patient that you will apply to the care of future patients? [Show Less]