CLIENT/PATIENT DATA SHEET/PLAN OF CARE



CLIENT/PATIENT DATA SHEET/PLAN OF CARE

(ACUTE CARE)

Student Name _______________________ Date of Care_______________________________________

Instructor Name ______________________ Unit ____________________________ Room # ________

| |For the client’s primary diagnosis, integrate knowledge of physiology, pathophysiology and|

|Client/patient initials________ Admit date___________ |psychosocial elements with pertinent client/patient history, and physical assessment data.|

| |(Use back or separate page as needed). |

|Diagnosis (admit) _______________________________ | |

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|Current Surgery (with date)________________________ | |

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|Signs & Sx (on admit)____________________________ | |

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|Medical History_________________________________ | |

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|______________________________________________ | |

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|MD __________________________________________ | |

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|Age ___ Gender____ Allergies____________________ | |

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|CODE STATUS ________________________________ | |

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|Hgt _______Admit wgt_____ Current wgt____________ | |

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|Admission VS__________________________________ | |

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|Activity Level ____________ Diet _________________ | |

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|IV (solution and rate)_____________________________ | |

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|PCA/Epidural (drug/dosage)_______________________ | |

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|Support tubes type/special orders____________________ | |

| |*Must cite references of resources utilized. |

|Support System _________________________________ | |

PLAN OF CARE (complete this section prior to taking care of the client/patient)

|ANTICIPATED PRIORITY FOCUSED ASSESSMENT |PROJECTED PRIORITY NURSING DIAGNOSIS with EXPECTED |PROJECTED NURSING INTERVENTIONS with RATIONALES |

|(INCLUDE RATIONALE) |OUTCOME |(minimum 3) |

| |(INCLUDE RATIONALE) |(only 1 r/t assessment or monitoring) |

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| |EXPECTED OUTCOME: | |

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CLIENT/PATIENT DATA SHEET/PLAN OF CARE

|Date |DIAGNOSTIC TESTS (labs, imaging, etc.) |INTERPRET LAB VALUES & DIAGNOSTIC FINDINGS: If |SIGNS & SYMPTOMS YOU WILL BE LOOKING FOR IN THIS |

|of Test |PERTINENT TO CLIENT/PATIENT CONDITION |abnormal, explain why it is abnormal in relationship to|CLIENT AS A RESULT OF THIS ABNORMAL LAB VALUE OR |

| |(put normal values in parentheses) |patient’s diagnosis, history and/or disease process; if|DIAGNOSTIC TEST. |

| | |normal, explain why it would be important to monitor | |

| | |this lab value in this patient (consider diagnosis, | |

| | |patho, etc.) | |

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*Must cite references of resources utilized.

MEDICATIONS

• List all scheduled medications by TRADE & (generic) names and any PRN medication(s) administered within the last 24 hours.

• Provide client/patient specific rationale for medication (for what specific client condition was this medication ordered – condition should be evident in diagnosis, history, pathophysiology and/or labs)

• Identify allergies to medications and any incompatibilities between medications/IV infusions

• For each medication, identify specific nursing implications pertinent to giving medication safely/effectively.

• Student must be prepared to discuss mechanism of action, pharmacologic classification, & major SE’s.

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*Must cite references of resources utilized.

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