Concepts II NUR 163
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
STUDENT NAME:
DATE/ Clinical
PATIENT INITIALS:
ALLERGIES/ Reaction to:
AGE:
DATE/Admission:
LMP: (mark n/a if not applicable)
PAIN: Is client experiencing any pain?
Verbal/nonverbal
GRAVIDA:
Pain Scale used:
Location:
Duration:
Character
RELIGION: How does it affect their care?
Height:
PARA:
Weight:
AB:
BMI:
CHIEF COMPLAINT in PT’s own words:
HISTORY OF PRESENT ILLNESS
How, when, where, what and why; of the chief complaint
PAST MEDICAL HISTORY
CURRENT ORDERS
DIET:
ACTIVITY:
TREATMENTS:
Time
1
BP
HR
RR
02Sats
Blood Sugars
Coverage
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PHYSICAL ASSESSMENT/ On Going throughout day
(Complete head to toe assessment. WNL is not accepted. Please be specific.)
Inspect: Neck; ROM, tenderness, holds head, nodes, thyroid, lymph nodes, swelling, masses, carotid
arteries, and pulses. PERRLA: Pain: descriptive pain, not a scale; reassess pain and its consistency
Hair: (texture, parasites, hygiene)
LOC: Orientation: (x4, time, person, place, and situation); Speech: Cranial Nerve Assessment
Neurologic:
from I-XII, (reassess if an intervention was performed)
Breast: shape, (assess symmetry, texture, lesions, nipple (any drainage), only by pt’s permission.
Respiratory:
Chest symmetry, shape, Lung sounds bilaterally; cough, sputum (color, amount, and consistency)
Tubes, O2 and SATs; trachea midline; respiratory rate; SOB, accessory muscles, assess mucus
membranes,
(reassess if an intervention was performed)
Cardiovascular: Rhythm (regular, weak, or strong); Apical pulse; capillary refill; auscultate heart sounds 1-5 points;
check for artificial devices; Peripheral Pulses: rate on scale of 0-4(distal, pedal, equal, strong, or
weak, and edema +1, 2, 3 or pitting), JVD presence.
(reassess if an intervention was performed)
Gastrointestinal: Dentition: (pt’s teeth, or dentures): Abdomen appearance (soft, round, palpate for tenderness or
masses); Bowel Sounds (location, x4 quadrants, hyperactive, hypoactive, or normal active); last BM
Stool (color, consistency, amount, date, texture, painful defecation) Occult blood; Tubes; Ostomies:
(stoma location, appearance)
(reassess if an intervention was performed)
Urethra drainage devises: Foleys: urine amt in bag, Urine: (color, odor, consistency, sediment,
Genitourinary:
frequency, voids, continent or incontinent, any difficulties); Vaginal area: (drainage, odor, lesions,
itching, pain, redness, swelling) Penis/Scrotum: (appearance, circumcision, drainage, itching, pain)
(reassess if an intervention was performed)
Musculoskeletal: ROM: (active, passive, paralysis, strengths, weaknesses, grips, gait, appearances, skeletal muscle
defects, tubes/lines, casts) Muscle strength: Rate on scale of 0-5 (reflexes, coordination, sensations)
Vertebral column: (symmetry, normal curvature, Scoliosis, Lordosis, etc) Mobile Devises: (W/C,
walker, etc)
(reassess if an intervention was performed)
Integumentary: Skin: (color, integrity, temp, moisture, texture, turgor, insertion sites, dressings, bruising, purpura,
rashes) Nails: (color, texture, shape)
(reassess if an intervention was performed)
Document: Family dynamics: (patient/family complaints, concerns, parental/guardian interactions
Psychosocial:
with pt, healthcare interest, home situations, Does pt. feel safe in the home? Any excessive alcohol
use, or excessive drug use, prescription or non-prescription, does pt smoke) Behavior: (mood and
affect) Appearance: (hygiene, age, position, posture, expression) Pt’s Roles; Significant
Relationships; Support Systems; What are pt’s Spiritual, Religious, and Cultural beliefs?
(reassess if an intervention was performed)
DEVELOPMENTAL ASSESSMENT
PIAGET’S STAGE:
EVIDENCE:
ERIKSON’S STAGE:
EVIDENCE
Diet: (Special diets, appetite, percentage of food eaten, and ability to feed self, feeding tubes, food
Nutritional:
allergies) Nutritional Supplements: (ensure, etc.) Significant weight loss or gain in last 30 days
(reassess if an intervention was performed)
HEENT
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MEDICATIONS
Don’t copy/paste
Include ALL medications patient is currently taking
Unless otherwise advised by instructor
Name/Dose
Frequency/route
safe dose
Classification Name
Action of
medication to
organs
targeted, and
actions on the
organ
Reason patient is
receiving this
specific
medication.
Therapeutic event
Side effects/ Adverse
effects or unexpected
findings pertinent to
patient
Nursing actions r/t
need of the client
Nursing Actions:
Patient Education:
Trade Name
Pts weight
Name/Dose
Frequency/route
safe dose
Classification Name
Action of
medication to
organs
targeted, and
actions on the
organ
Reason patient is
receiving this
specific medication
Therapeutic event
Side effects/ Adverse
effects or unexpected
findings pertinent to
patient
Nursing actions r/t
need of the client
Nursing Actions:
Patient Education:
Trade Name
Pts weight
Name/Dose
Frequency/route
safe dose
Classification Name
Action of
medication to
organs
targeted, and
actions on the
organ
Reason patient is
receiving this
specific medication
Therapeutic event
Side effects/ Adverse
effects or unexpected
findings pertinent to
patient
Nursing actions r/t
need of the client
Nursing Actions:
Patient Education:
Trade Name
Pts weight
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Name/Dose
Frequency/route
safe dose
Classification Name
Action of
medication to
organs
targeted, and
actions on the
organ
Reason patient is
receiving this
specific medication
Therapeutic event
Side effects/ Adverse
effects or unexpected
findings pertinent to
patient
Nursing actions r/t
need of the client
Nursing Actions:
Patient Education:
Trade Name
Pts weight
Name/Dose
Frequency/route
safe dose
Classification Name
Action of
medication to
organs
targeted, and
actions on the
organ
Reason patient is
receiving this
specific medication
Therapeutic event
Side effects/ Adverse
effects or unexpected
findings pertinent to
patient
Nursing actions r/t
need of the client
Nursing Actions:
Patient Education:
Trade Name
Pts weight
LAB DATA & DIAGNOSTIC EVALUATION
If the patient does not have recent labs/diagnostic tests,
Write what would be indicated for a patient with this diagnosis
Include diagnostic test like X-rays, CTs, and MRIs
LAB Ordered
LAB Ordered
4
Client
. Values:
Client
Values
Include date
Normal
Values
Normal
Values
Indication for Diseases / Illness
Why is the lab drawn? If level low/high specify why r/t
the patient’s condition or meds?
Indication for Diseases / Illness
Why is the lab drawn? If level low/high specify why r/t
patient’s condition or meds?
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Diagnostic test like X-rays,
CTs, and MRIs
Client Values
Indications for Disease/ Illness
MEDICAL DIAGNOSIS
Anything that affects their admitting condition (diagnosis) or affects their care.
MEDICAL DIAGNOSIS
(Current)
TEXTBOOK CLINICAL
PICTURE
Definition, Signs, and
Symptoms that should be
seen
CLIENT’S ACTUAL CLINICAL
PICTURE
What Signs and Symptoms your patient
actually exhibited
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS
List all nursing diagnosis relevant to patient condition & based on assessment
1.
2.
3.
4.
5.
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NURSING CARE PLAN
Student Name: ____________
Date: ____________________
Class: ______
Patient Initials: _______________
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related
to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one/ “expected outcome” measurable goal per nursing diagnosis stated in
terms of client achievement - “the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the
action you will use to work toward that goal.
NURSING
DIAGNOSIS
(NANDA
APPROVED)
6
EXPECTED
OUTCOME
(Measurable Goal with
dates)
ST: within time frame
of clinical
LT: can be outside of
time frame of clinical
NURSING INTERVENTIONS
RATIONALE
EVALUATION
(What do you plan to do for the client to
accomplish the goal? Be specific and
include time frames)
(Why are you doing this?)
Citation for each rationale
(If goal not met, need to evaluate
why? And what to do to met goal?)
ST:
ST:
LT:
LT:
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NURSING
DIAGNOSIS
(NANDA
APPROVED)
7
EXPECTED
OUTCOME
NURSING INTERVENTIONS
RATIONALE
EVALUATION
(Measurable Goal with
dates)
ST: within time frame
of clinical
LT: can be outside of
time frame of clinical
(What do you plan to do for the client to
accomplish the goal? Be specific and
include time frames)
(Why are you doing this?)
Citation for each rationale
(If goal not met, need to evaluate
why? And what to do to met goal?)
ST:
ST:
LT:
LT:
TCD/10-07
NURSING
DIAGNOSIS
(NANDA
APPROVED)
EXPECTED
OUTCOME
(Measurable Goal
with dates)
ST: within time frame of
clinical
LT: can be outside of
time frame of clinical
8
NURSING INTERVENTIONS
RATIONALE
EVALUATION
(What do you plan to do for the client to
accomplish the goal? Be specific and
include time frames)
(Why are you doing this?)
Citation for each rationale
(If goal not met, need to evaluate
why? And what to do to met goal?)
ST:
ST:
LT:
LT:
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References
(APA format)
Set font style to Times New Roman, font size 12 font.
Type in and save as Microsoft Word program/document or convert to Word prior to sending via email.
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Care Plan Grading Matrix
Section
Score
Possible Points
Demographic Data
Name (student/pt initials), Date, Age, Pain score, Growth
Measurements, CC, HPI, PMH, Current Orders, Developmental
Assessment
10
Physical Assessment
25
Medication
10
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing Diagnosis One-part statements
5
Nursing Care Plan
(Dx statements 3-part statements– minimum of 3, Goals –
short & long term, Interventions – minimum of 3, Rationales – 1
for each intervention, Evaluation)
30
Citations, References & APA format
10
Total
10
100%
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