CARE PLAN’S & ASSESSMENTS
MS JACKSON
02/2019
CARE PLAN & ASSESSMENTS
• ASSESSMENT:
• HEAD TO TOE
• WHAT DOES THAT MEAN?
• YOU DO YOUR ASSESSMENT FIRST THING
• START WITH THE HEAD AND WORK TO THE TOES
• USE YOUR RESOURCES OF CLINICAL SYSTEMS AND CHARTING TERMS
• ALWAYS HAVE THE TOOLS OF YOUR TRADE
• ALWAYS REMEMBER : MAYA ANGELOU ‘S SAYING: PEOPLE MAY FORGET WHAT YOU SAY,
PEOPLE MAY FORGET WHAT YOU DO,
BUT PEOPLE WILL NEVER FORGET HOW YOU MADE THEM FEEL!
CLIENT DATA/GENERAL SURVEY

Name

Age

Allergies

Code Status (DNR)

Vital Signs T, P, R, B/P

Environment setting

Chief Complaint (quote)

ABC’s
Appearance- posture/position, dress, grooming, and hygiene
Behavior- level of consciousness, facial expression, mood/affect
Communication- can patient make needs known
1
NEUROLOGIC ASSESSMENT

Level of Consciousness-Alert, oriented X 3

Memory (3 words given, etc.)

Speech (slurred, slow)

PERRLA

Abnormal movements, CN intact?
Musculoskeletal

Full Range of Motion

Strength of extremities (= & strong)

Ambulation (describe)

Independent /Needs Assistance
Head:
* HAIR: disbursed appropriately? Nails-clubbed, cap refill, ridged, etc
*EYES: sclera, conjunctiva, drainage; EARS: dranage,problems noted?
*NOSE: dranage,discolored, deformed, misshaped? MUTH: drooling, drooping, mucous
membranes,?
2
RESPIRATORY ASSESSMENT

Rate, rhythm, depth

Labored breathing? (dyspnea, accessory muscles, nasal flaring, retractions)

Cough (frequency, production)

Describe mucus (color, consistency, amount)

O2 Therapy (cannula, mask, # liters, tubing irritation 02 Sat)

Breath Sounds ( ant, post, and lateral) BBS clear to all lobes, all lobes CTA (clear to
auscultation)

Midline trach
CARDIOVASCULAR ASSESSMENT

Edema (non-pitting or pitting-+1,m +2, +3)

Apical pulse- (1 min) (rate, rhythm, quality) Listen these area
(aortic, pulmonic, tricuspid, mitral)

Heart sounds- S1 & S2 present and regular or irregular

Peripheral pulses (= & strong X 4)

Apical Impulse-palpable or non-palpable

AP=RP

JVD PMI Can they lie flat SOB at rest or at exertion
NEUROVASCULAR ASSESSMENT
Circulation Movement
Sensation
color
wiggle
feeling
temp
fingers/toes
pain
cap refill
numbness
pulses
tingling
edema
burning
4
SKIN/HYDRATION ASSESSMENT

Skin color, temp, turgor, moisture, intact? Lips, mucus membranes
color and moisture (lower ext. discolored if present)

Red areas, lesions, rashes

Wounds: size, location, color, odor, drainage

Preventive breakdown measures in effect? i.e. egg crate mattress

IV’s location, type, fluid, rate (dry intact drsg r soiled & wet, etc)
PAIN ASSESSMENT

Location? Intensity? Onset? Duration? Rate 0-10

Character? Precipitation or aggravating factors

Relief measures? Last med taken?
5
GI/GU ASSESSMENT

Bowel sound (x 4 quads)

Distention? Tender? Soft, Hard?

Flatus? N/V?

Diet/ Appetite

NG or PEG

Last BM? Normal Pattern? Aides?

Bladder status: amount? Dysuria/ distention? (pain)

Urine: color? Clarity? Odor?

Catheter? (draininag to BSD, urometer, etc)
3
6
CARE PLAN S & ASSESSMENTS
• SIGNIFICANCE TO YOUR PATIENT CONDITION AND/OR DIAGNOSIS
• WHY WAS THIS TEST DONE ON THIS PATIENT?
• TO TEST FOR BLOOD LOSS?
• ELECTROLYTE IMBALANCE?
• HEART ATTACK? ETC.
• YOU HAVE TO TELL US WHY THIS TEST WAS DONE ON YOUR PATIENT EVEN IF PARAMETERS ARE IN RANGE.
CARE PLAN S & ASSESSMENTS
• CARE PLAN
• BRING YOUR ASSESSMENT AND DATA (SUBJECTIVE & OBJECTIVE) TO YOUR CARE PLAN (CP).
• PULL OUT YOUR NANDA LIST AND WRITE DOWN ALL THAT APPLY TO YOUR PATIENT
• PRIORITIZE YOUR LIST
• DECIDE THE MOST IMPORTANT AND DO YOUR CP ON THIS/THOSE
• WRITE YOUR PES (PATIENT DIAGNOSTIC STATEMENT)-WHERE U OUT IT ALL TOGETHER
• NANDA-THE PROBLEM
• RELATED TO-WHY YOUR PATIENT HAS THE PROBLEM AND WHY IT IS A PROBLEM (ETIOLOGY/CAUSE)
• AS EVIDENCED BY-WHAT SINGS/SYMPTOMS THE PATIENT HAS TO MAKE THIS THE PROBLEM
• DEFINING CHARACTERISTICS –FROM- SOURCE AND PAGE NUMBER! - YOUR BOOKS OR OTHER APPROVED SOURCE
CARE PLAN S & ASSESSMENTS
• PRIORITIZE YOUR NURSING DIAGNOSIS
• GO THRU YOUR LIST AND WRITE DOWN ALL THAT APPLY TO YOUR PATIENT
• PRIORITIZE THEM IN 1,2,3 ORDER
• A, B, C’S FIRST
• GET YOUR NANDA LIST (IN FRONT OF YOUR BOOK)
• GO OVER THE LIST-WHAT APPLIES TO YOUR PATIENT
• PUT THEN IN ORDER OF IMPORTANCE
CARE PLAN S & ASSESSMENTS
• NANDA
• AFTER PLACING THEM IN ORDER OF IMPORTANCE DECIDE ON THE
PSYCHOLOGICAL
PSYCHOSOCIAL
KNOWLEDGE DEFICIT
CARE PLAN S & ASSESSMENTS
• RELATED TO:
• WHAT IS CAUSING THE PROBLEM
• WHAT IS THE ETIOLOGY
• RESULT FOR ETIOLOGY:
• THE CAUSE, SET OF CAUSES, OR MANNER OF CAUSATION OF A DISEASE OR CONDITION.
• THE INVESTIGATION OR ATTRIBUTION OF THE CAUSE OR REASON FOR SOMETHING…
• WWW.MIRIAMWEBSTER.COM
CARE PLAN S & ASSESSMENTS
• AS EVIDENCED BY:
• WHAT EVIDENCE DO YOU HAVE TO SUPPORT YOUR DIAGNOSIS.
• EX: IF YOU USED EXCESS FLUID (CHF) YOU MAY USED
• R/T BNP OF 62,000
CARE PLAN S & ASSESSMENTS
• AS EVIDENCED BY (SIGNS AND SYMPTOMS)
• AEB:
• INABILITY TO LIE FLAT IN BED
• EVIDENCE OF JVD
• +3 PITTING EDEMA
• SOB ON EXERTION
• ETC.
CARE PLAN S & ASSESSMENTS
• DEFINING CHARACTERISTICS:
• FACTORS THAT MAKE YOUR DIAGNOSIS STAND.
• THIS IS FROM YOUR SOURCE (BOOK, OR APPROVED SOURCE)
• FIND SOMETHING IN YOUR SOURCE THAT REFLECTS WHAT YOU HAVE
• PITTING EDEMA, JVD, BNP, SOB, ETC
CARE PLAN S & ASSESSMENTS
• PES: PATIENT DIAGNOSTIC STATEMENT:
• PUTTING IT ALL TOGETHER:
• DIAGNOSIS- R/T- AEB
• WRITE IT ALL IN A SENTENCE.
• DOES IT MAKE SENSE TO YOU
• DOES IT FIT
• WHEN YOU READ IT CAN YOU SEE THE PICTURE YOU ARE TRYING TO PAINT
CARE PLAN S & ASSESSMENTS
• PLAN: WHAT THE PATIENT WILL DO AND TIMEFRAME. (EX: THE PT WILL DANGLE TO BEDSIDE
BEFORE AMBULATING S/P SURGERY BY 12 NOON)
• IMPLEMENTATION: (2 EXAMPLES IS YOU CHOOSE)
• PATIENT ORIENTED: WHAT THE PATIENT WILL DO AND HOW YOU AS THE NURSE WILL MAKE THIS
HAPPEN. THIS IS NOT ABOUT THE NURSE BUT ABOUT THE PATIENT.
• EX: THE PT WILL DANGLE AT BEDSIDE TWICE BEFORE LUNCH, HOB WILL BE RAISED UPRIGHT AND PT
TURNED TO DANGLE FOR15 MIN AND BACK TO BED (THIS COULD ALSO BE THE RATIONALE AND PUT
IN THAT SECTION SAYING HOW THIS WILL HELP THE PT TO GET READY TO AMBULATE, ETC)
• EX: HOB ELEVATED AND LEGS TO BEDSIDE TO DANGLE 15 MIN.
CARE PLAN S & ASSESSMENTS
• RATIONALE
• LOOK UP THE REASON WHY YOU WILL DO THIS IMPLICATION AND BE SURE AND PUT YOUR
REFERENCE AND PAGE NUMBER FOR EACH INTERVENTION.
• EX: DANGLING A PATIENT AT BEDSIDE CAN PREVENT FALL AND INJURY WHEN THEY RISE TO AMBULATE.
LEWIS PAGE 550; POTTER AND PERRY P 990.(2 REFERENCES FOR RATIONALE-ONE BOOK FOR 1 RATIONALE
AND ANOTHER FOR 2ND RATIONALE, ETC.)
• WAS THE TASK COMPLETED-IF SO PUT A CHECK IN THE COMPLETE COLUMN, IF IT DID NOT WORK OR THE
PATIENT COULD NOT TOLERATE IT POUT IT COULD NOT BE COMPLETED.
CARE PLAN S & ASSESSMENTS
• EVALUATION
• HOW WELL DID THE PLAN WORK? DO WE USE WORDS LIKE AWESOME, GREAT, COULDN’T HAVE GONE
BETTER? NO JUST SAY THE PLAN WORKED WELL OR THE PLAN DID NOT WORK AT THIS TIME
• WHAT REVISIONS ARE NEEDED? NONE AT THIS TIME. OR PATIENT NEEDS TO DANGLE MORE OFTEN TO
PREPARE FOR AMBULATION.
• HAVE YOUR PRIORITIES CHANGED? NOT AT THIS TIME, OR IF NEED CHANGE PUT IT DOWN.
• THE DESIRED OUTCOME WAS OR WAS NOT OR WAS PARTIALLY MET. MARK THE ONE PERTAINING
• THE PATIENT EXHIBITED THE FOLLOWING: DESCRIBE PATIENT BEHAVIORS OR RESPONSES- THE PATIENT
WAS ABLE TO DANGLE TWO TIMES AT 15 MIN INTERVALS PRIOR TO AMBULATING S/P SURGERY
CARE PLAN S & ASSESSMENTS
• DRUG SHEETS OR CARDS
• YOUR CLINICAL INSTRUCTOR WILL LET YOU KNOW WHICH DRUGS THEY WANT YOU TO PLACE ON
THE SHEETS.
• YOU DO NOT HAVE TO PLACE PRN MEDS ON THE SHEETS
DO NOT FORGET QSEN AND 60 SEC SAFETY SHEETS AS WELL
CARE PLAN S & ASSESSMENTS
QUESTION AND ANSWER TIME