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Instructions:
During the NSG125 Transition to Professional Nursing course, students will complete a total of one care plan assignment as follows:
1. Care Plan based on a simulated client case from Shadow Health – OR
2. Care Plan based on a clinical site client.
Care Plan Map Components:
· Part I: Physical Assessment
· Part II: History & Physical
· Part III: Medications
· Part IV: Diagnostic Studies & Interpretation/Assessment Explanation
· Part V: Clinical Judgement Measurement Model Table
Rubric: Must achieve 16 points to pass clinical.
1. Care Plan based on a simulated client case- OR a Care Plan based on a clinical site client
| Criteria | 4 points | 3 points | 2 points | 0 points | Total Points |
| Part I: Physical Assessment | All components of the physical assessment are present. | Most of the information is provided with all areas addressed. No more than 3 missing areas. | No more than 6 of the assessment areas are lacking information. | Assessment information not provided | |
| Part II: History & Physical | Information is complete and accurate; All areas of the section are addressed. | Most of the information is provided with all areas addressed. No more than 3 missing areas. | No more than 6 of the history & physical areas are lacking information. | Assessment information not provided | |
| Part III: Medications | Information is complete and accurate; All areas of the section are addressed. | Most of the information is provided with all areas addressed. No more than 3 missing areas. | No more than 6 of the history & physical areas are lacking information. | Assessment information not provided | |
| Part IV:
Diagnostic Studies & Interpretation/Assessment Explanation |
Information is complete and accurate; All areas of the section are addressed. | Most of the information is provided with all areas addressed. No more than 3 missing areas. | No more than 6 of the history & physical areas are lacking information. | Assessment information not provided | |
| Part V: Clinical Judgement Measurement Model Table | Information is complete and accurate; All areas of the section are addressed. | Most of the information is provided with all areas addressed. No more than 3 missing areas. | No more than 6 of the history & physical areas are lacking information. | Assessment information not provided | |
| Total points | /20 |
Part I: Physical Assessment
VS Time: Temperature Pulse Respirations BP / Pain /10
VS Time: Temperature Pulse Respirations BP / Pain /10
| GENERAL SURVEY | |
| Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic
Height___________ Weight____________ Well-groomed Poorly Groomed Facial Expression: Content Happy Anxious Sad Angry Flat |
|
| NEUROLOGICAL | |
| (LOC) Level of
Consciousness |
Alert Awake Lethargic Obtunded Stupor Comatose Confused
Oriented x 4:
If not alert X 4, circle what they are alert to: Person Place Time Situation
|
| Eyes | Unaided sight Glasses Contact lens Blind |
| Pupils | Equal Round Reactive to light Accommodates List abnormal findings:________________________________________
Pupil reaction: Brisk Sluggish Nonreactive to light Pupil size: before light ______mm after light ______mm |
| Ears | Unaided hearing Hard of hearing Deaf Hearing aid Implant |
| Extremity Strength | Hand grips +1 +2 +3 +4 +5 equal unequal
Foot pushes +1 +2 +3 +4 +5 equal unequal
|
| Pain | Location:
Onset (when did it start):
Provokes (makes it worse):
Palliates (makes it better):
Quality (description):
Radiate: location:
Severity: ___/10
Time: Constant Intermittent |
| CARDIOVASCULAR | |
| Skin / Mucous Membranes | Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic |
| Radial and Pedal Pulses | Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent
Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent |
| Apical Radial Pulses | (2 assessed simultaneously) Equal Pulse Deficit |
| Capillary Refill | Normal (<3 Sec) ______sec Location:________________ |
| Edema | Absent Present: location +1 +2 +3 +4 Non-Pitting |
| Heart Rhythm/
Sounds – S1S2 |
Heart Rhythm: Regular Irregular
Heart Sounds: S1/S2 Murmur Extra Sounds
Sound: Strong Distant
|
| IV | None
Solution_______________ Rate ____ml/hr Site location (be specific) ______________________________________ Site appearance: WNL Edema Erythema Tender Pallor Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________ |
| RESPIRATORY | |
| Respirations | Pattern: Regular Irregular
Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction
Chest Expansion: Symmetrical Asymmetrical |
| Lung Sounds | Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______
Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______
|
| Cough | None Non-productive Productive Sputum: amount color |
| Oxygen | Room air O2 at_____L/min
Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask |
| Respiratory Treatments | Incentive Spirometer (IS): ml______ # of times______
Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________ |
| GASTROINTESTINAL | |
| Oral | Mouth: Teeth Dentures Caries
Swallowing: Gag reflex Dysphagia
Mucous Membranes: intact moist dry pale pink |
| Abdomen:
|
Contour: Soft Round Flat Scaphoid Obese
Palpation: Firm Hard Tender Non-Tender Location:
Distention: Nondistended Distended |
| Bowel Sounds | RLQ Normoactive Hypoactive Hyperactive Absent
RUQ Normoactive Hypoactive Hyperactive Absent
LUQ Normoactive Hypoactive Hyperactive Absent
LLQ Normoactive Hypoactive Hyperactive Absent |
| NG/ GT/ JT | None
Type of tube _____ patent non-patent Purpose: Suction Feeding Medication Administration
Type of food: _________ Fluid Flush__________mL
|
| Bowel Movement | Continent Incontinent
Last BM__________ Color Consistency
Ostomy: yes no |
| Nutrition | Self-feed Needs assistance
Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________ Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed
Tube Feed: Yes or No
|
| GENITOURINARY | |
| Urine | Continent Incontinent
Urgency Hesitancy Frequency Burning Nocturia Catheter type _______________ None Color_________________ Clear Cloudy Sediment Burning Frequency
|
| Intake and Output | PO/Oral/Tube Feed intake____________ mL
IV intake____________ mL Urine output_________ mL Other output_________ mL Fluid restriction ___________mL/day
|
| MUSCULOSKELETAL | |
| ROM | Active ROM: Completed____________ Passive ROM: Completed____________ |
| Mobility | Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair
Walks: distance frequency tolerance PT OT |
| Other Musculoskeletal | Cast: Location:
Brace: Type: Location:
Amputation: Location:
|
| Risk for Falls | Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board |
| INTEGUMENTARY | |
| Appearance | Color: Normal for Ethnicity Pallor Rash Bruise Lesions
Intact OR Non-Intact: Location of Non-Intact Areas_____________________________________________________ New Scars: Location _________________________ Dressing change: (describe: location, steps, drainage, wound)
|
| Temperature and Moisture | Temperature: Warm Hot Cool Cold
Moisture: Dry Moist
|
| Incisions/Wound | None
Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________
Wounds Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough
|
| PSYCHOSOCIAL | |
| Behavior | Cooperative Uncooperative
Pleasant Withdrawn Combative Other_______________ |
| Language spoken | English = speaks and understands other_________________ Interpreter |
| Part II: History and Physical | |
| Nursing Care Plan: | Date: |
| A. Client identifiers:
Physician (s): Age: Gender: Ht: Wt. Code Status: Isolation Status: |
|
| Health States | |
| Date of admission:
Activity level: Diet: Fall risk:
Client’s chief complaint:
Client’s past medical and surgical history
Allergies:
|
Mobility needs: (Independent, partially-dependent, full-assist)
Interdisciplinary Consults (PT/OT/RT/ST/other):
Referrals to Specialists (pulmonary, cardiac, neuro, etc.) |
| Socio-cultural Orientation | |
| Cultural and Ethnic Background
Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, and financial abuse)
Barriers to independent living
|
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| Part III. Medications | ||||
| List medications, dosages, classifications, and the rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication. A maximum of twelve (12) medications focus on the medication corresponding to the patient’s primary and chronic health conditions. | ||||
| ALLERGIES: | ||||
| Medication, Classification, Mechanism of Action |
Dosage/Route |
Contraindications, Adverse Reactions/Side Effects, Risk Factors, |
Client Education and Nursing Implications |
Why is this client getting this medication? |
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| PART IV: Diagnostic studies and Interpretation (Maximum of 5 lab values) | ||||
| Labs | Normal Values | Results | What do these results indicate? | Identify 2 interventions based on the laboratory findings (examples: Medications, procedures, positioning) |
| Assessment Explanation | |
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Identify three (3) nursing interventions based on the Physical Assessment findings |
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State the educational needs of this client. |
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NSG125 Transition to Professional Nursing- Care Plan
9 Revised:11/17/2023
PART V: Clinical Judgement Measurement Model Table
| Recognize Cues
Identify five (5) abnormal Signs, symptoms, risk factors, labs, and health history, clinical manifestations. |
Prioritize
Using the Recognize Cues column to prioritize the chief complaints |
Generate Solutions
List three (3) nursing interventions needed for this client. Use the three (3) interventions identified above. |
Evaluate Outcomes
How would you determine the effectiveness of your nursing interventions? |
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