4 Care Plans
CARE PLAN WORKSHEET
Student’s Name: | |
Date/Time: | |
Client’s Initials: | |
Admission Date: | |
Age: | |
Sex: | |
Race: | |
Religion: | |
Allergies: | |
Diet: | |
Activity: | |
Admitting Medical Diagnosis: | |
Past Medical History: | |
Past Surgical History: | |
History of Present Illness: | |
Client Understanding of Illness: |
PATHOPHYSIOLOGY |
|
What Medications are you currently taking at home?
MEDICATION | TIME(S) | WHY? |
Are your medications causing you any discomfort? |
|
OVERVIEW MEDICATION(S) WORKSHEET (TOPICAL, PO, IM, SQ, IV)
NAME/CLASSIFICATION
|
DOSE/ROUTEFREQUENCY SAFE RANGE | MECHANISM OF ACTION | INDICATIONS | SIDE EFFECTS | NURSING CONSIDERATIONS AND PATIENT EDUCATION |
Chemistry | Normal Values | Date | Date
|
Hematology | Normal Values | Date
|
Date |
Na | WBC | ||||||
K | RBC | ||||||
Cl | Hgb | ||||||
CO2 | Hct | ||||||
Ca | MCV | ||||||
Glucose | MCH | ||||||
BUN | MCHC | ||||||
Creatinine | Platelets | ||||||
Phosphorus | |||||||
Cholesterol | DIFFERENTIAL | ||||||
Total Protein | Neutrophils | ||||||
Albumin | Bands | ||||||
Alb/Glob Ratio | Lymphocytes | ||||||
AST (SGOT) | Monocytes | ||||||
ALT (SGPT) | Eosinophils | ||||||
Total Bilirubin | Basophils | ||||||
Amylase | |||||||
Lipase | COAGULATION | ||||||
LIPID PROFILE | PT | ||||||
Total Cholesterol | INR | ||||||
Triglycerides | PTT | ||||||
HDL | Bleeding Time | ||||||
LDL | Fibrinogen | ||||||
Chol/HDL Ratio | |||||||
GGT |
OTHER LABS:
Labs | Normal Values | Date | Date
|
Labs | Normal Values | Date
|
Date |
Relate the clinical significance of abnormal lab values above:
Abnormal Lab Value | Explain why lab value is abnormal |
DIAGNOSTIC PROCEDURES
Diagnostic Procedure | Report |
NURSING CARE PLAN
Assessment
Subjective/Objective Date |
Priority Nursing DX/Clinical Problem | Client Goals/Desired Outcomes/
Objectives |
Nursing Interventions/Actions/Orders and Rationale | Evaluation
|
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