NURS 115 ACC Shortness of Breath and Nausea Nursing Care Plan
Description
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Associate Degree in Nursing Program
Intermediate Medical Surgical Nursing URS115C
NURSING CARE PLAN
Student Name
Clinical Location
Clinical Instructor
Cohort
Patient Initials
Admit Date
Care Date
Allergies:
Do not leave blank
Age
ADMISSION DATA
Gender
Occupation
Date
Languages Spoken
Spiritual Beliefs
Chief Complaint/Reason for Hospitalization (in patientàown words):
What brought the patient to the hospital? This response should be in the patient’s own words. If the patient is unable to verbalize, explain reason here.
Medical Diagnoses
Relevant Surgical History
All diagnoses for current admission.
Past Medical History:
Education Needs:
Do not leave blank. All patients need education. Start with education
relating to the primary health problem.
As nurses, we promote health. That includes education on
medication, diet, safety/injury prevention, etc. SPECIFIC to YOUR
patient.
Language Barrier:
Social History:
?None
?ESL
?Speech Impediment
?Intubated
?Tracheostomy
?
Other:
Code Status:
?Full Code
Advance Directives (Nursing Admission Assessment)
?DNR
?Other (specify):
Durable Power of Attorney: ?Yes
Living Will:
?Yes ?No
Current Medications
Dose, Frequency, Time, Route
Generic/Trade Name/Classification
Ex: One 325mg tab Q 4 hours PO
Generic & Trade Name & Classification
All 3 components should be included here.
?No
Indication(s) prescribed for:
Why does your patient need this?
What are the nursing considerations?
2 parts should be mentioned here. Why is YOUR patient
taking this medication? AND what are the nursing
considerations for this medication?
Current Medications
Dose, Frequency, Time, Route
Indication(s) prescribed for:
Admission Data NOTES:
Do not leave blank. The NOTES section is primarily for identifying abnormal data. If the patient has no abnormal data, simply add a statement that
says so.
ASSESSMENT DATA ABORATORY VALUES
Indicate abnormal results with a or
Test
Normal Range
SAMPLE
4-5
Current
Value
On Admission
3
L
3.5
L
Test
Normal Range
SAMPLE 2
10-20
Sodium
135-145mEq/L
Potassium
3.5-5.0 mEq/L
Chloride
98-109 mEq/L
Magnesium
1.3-2.1 mEq/L
Phosphorus
Urine Spec
Gravity
BUN
2.5-4.5 mEq/L
Creatinine
0.6-1.2mg/dL
Calcium
M 13-18gm/dL
F 12-16gm/dL
M 37-49%
F 36-46%
150-400K mm3
M 4.6-6.2 mm3
F 4.2-5.4 mm3
8.5-10.5 mEq/L
WBC
5-10.8K mm3
PT
INR
10-13 seconds
0.8-1.1
INR on Warfarin
2-3
PTT
20-45 seconds
GFR
HgbA1C
PH Level
Purchase answer to see full
attachment
Intermediate Medical Surgical Nursing URS115C
NURSING CARE PLAN
Student Name
Clinical Location
Clinical Instructor
Cohort
Patient Initials
Admit Date
Care Date
Allergies:
Do not leave blank
Age
ADMISSION DATA
Gender
Occupation
Date
Languages Spoken
Spiritual Beliefs
Chief Complaint/Reason for Hospitalization (in patientàown words):
What brought the patient to the hospital? This response should be in the patient’s own words. If the patient is unable to verbalize, explain reason here.
Medical Diagnoses
Relevant Surgical History
All diagnoses for current admission.
Past Medical History:
Education Needs:
Do not leave blank. All patients need education. Start with education
relating to the primary health problem.
As nurses, we promote health. That includes education on
medication, diet, safety/injury prevention, etc. SPECIFIC to YOUR
patient.
Language Barrier:
Social History:
?None
?ESL
?Speech Impediment
?Intubated
?Tracheostomy
?
Other:
Code Status:
?Full Code
Advance Directives (Nursing Admission Assessment)
?DNR
?Other (specify):
Durable Power of Attorney: ?Yes
Living Will:
?Yes ?No
Current Medications
Dose, Frequency, Time, Route
Generic/Trade Name/Classification
Ex: One 325mg tab Q 4 hours PO
Generic & Trade Name & Classification
All 3 components should be included here.
?No
Indication(s) prescribed for:
Why does your patient need this?
What are the nursing considerations?
2 parts should be mentioned here. Why is YOUR patient
taking this medication? AND what are the nursing
considerations for this medication?
Current Medications
Dose, Frequency, Time, Route
Indication(s) prescribed for:
Admission Data NOTES:
Do not leave blank. The NOTES section is primarily for identifying abnormal data. If the patient has no abnormal data, simply add a statement that
says so.
ASSESSMENT DATA ABORATORY VALUES
Indicate abnormal results with a or
Test
Normal Range
SAMPLE
4-5
Current
Value
On Admission
3
L
3.5
L
Test
Normal Range
SAMPLE 2
10-20
Sodium
135-145mEq/L
Potassium
3.5-5.0 mEq/L
Chloride
98-109 mEq/L
Magnesium
1.3-2.1 mEq/L
Phosphorus
Urine Spec
Gravity
BUN
2.5-4.5 mEq/L
Creatinine
0.6-1.2mg/dL
Calcium
M 13-18gm/dL
F 12-16gm/dL
M 37-49%
F 36-46%
150-400K mm3
M 4.6-6.2 mm3
F 4.2-5.4 mm3
8.5-10.5 mEq/L
WBC
5-10.8K mm3
PT
INR
10-13 seconds
0.8-1.1
INR on Warfarin
2-3
PTT
20-45 seconds
GFR
HgbA1C
PH Level
Purchase answer to see full
attachment
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