Client Care Plan
Client initials:
Sex:
Age:
Student:
Code status:
Cultural influences:
Diagnosis:
Surgery:
Date:
History of Present Illness (HPI)
Past Medical History (PMH)
Definitions, Abbreviations, Etiology/Risk Factors
Client Etiology/Client Risk Factors
Pathophysiology
Clinical Manifestations
Client Symptoms
Expected Diagnostic Evaluation
NS V40 Client Care Plan
1
Rev. 8/2005
Air
Data Gathering/Diagnostic Tests
PT
INR
PTT
ABGs:
pH
pCO2
pO2
HCO3
O2 Sat.
Base Excess
CBC:
WBC
RBC
Hgb
HCT
MCV
MCH
MCHC
Retic.
Sed. Rate
Platelets
Drug Serum Level:
Differential:
PMS (Segs &
Neutrophils)
Lymphs
Monocytes
Eosinophils
Basophils
Bands
CPK-MB
EKG:
C & S Sputum:
X-ray:
INTEGUMENTARY (color, temperature, moisture, oral mucosa, turgor, lesions, pruritus, dressings, wounds, incisions, drainage, erythema,
IV site)
RESPIRATORY (rate, rhythm, lung sounds, SOB, O2, cyanosis, TCBD, spirometer, tracheotomy, cough, sputum appearance)
CARDIAC (apical pulse rate & rhythm, blood pressure)
VASCULAR (venous distention, quality of peripheral pulses, edema, calf tenderness, capillary refill, paresthesia, pain)
Narrative Assessment
Pathophysiology
NANDAs
Airway clearance, ineffective
Aspiration, risk for
Breathing pattern, ineffective
Gas exchange, impaired
Suffocation, risk for
Skin integrity, impaired
Skin integrity, impaired risk
Cardiac output, decreased
Tissue perfusion,
altered
Dysreflexia
Knowledge deficit R/T
Non-compliance
Pain, acute/chronic
Troponin
BNP
NS V40 Client Care Plan
2
Rev. 8/2005
Digestive
Data Gathering/Diagnostic Tests
T. Protein
Albumin
Prealbumin
Globulin
A/G Ratio
Liver Test:
ALP
ALT
AST
GGT
LDH
Amylase
Bilirubin
Ammonia
Lipids:
CHOL
TRIG
HDL
LDL
VLDL
PKU
X-rays:
FOOD/WATER (Diet type, percent eaten, tolerance, IV, swallowing, weight gain or loss)
ELIMINATION (Genitourinary: color, amount, voiding pattern, catheter, dialysis, drainage tubes, odor, penile or vaginal discharge,
24 hour I & O)
GASTROINTESTINAL (Bowel sounds, abdomenal distention, palpation, last BM, frequency, pattern, ostomy, nausea, vomiting, flatus,
drainage tubes)
Narrative Assessment
Pathophysiology
Glucose
FSGB
Serum Iron
Ferritin
TIBC
Renal Test:
BUN
Creat.
Uric Acid
Electrolytes:
Na+
K+
Cl
CO2
Ca
Phos.
Mg
Urinalysis:
Spec. Gr.
pH
Protein
Glucose
WBC
RBC
Bacteria
Mucous Threads
NANDAs
Fluid volume deficit
Fluid volume deficit, risk for
Fluid volume, excess
Nutrition, altered: less/greater than
body requirement
Oral mucosa membrane
Swallowing, impaired
Infant feeding pattern, ineffective
Breast feeding
Incontinence, type
Urinary elimination, altered pattern
Urinary retention
Self-care deficit: toileting
Bowel incontinence
Constipation
Constipation: perceived/colonic
Diarrhea
Pain, acute/chronic
Knowledge deficit R/T
Non-compliance
Crystals
Stool:
Occult blood
O&P
NS V40 Client Care Plan
3
Rev. 8/2005
Normalcy
Data Gathering/Diagnostic Tests
Activity/Rest
Data Gathering/Diagnostic Tests
PSYCHOSOCIAL (Behavior, emotions, anxiety, depression, anger, thought disturbance, judgment, insight into illness)
Narrative Assessment
Pathophysiology
Anxiety
Ineffective patient/family coping
Powerlessness
Spiritual distress
Grieving
Body image disturbance
Social isolation
Confusion, acute/chronic
Knowledge deficit R/T
Non-compliance
MUSCULOSKELETAL (Activity level, ADL, gait, assistive devices, extremity movement, CMS of involved extremity,
PAIN (Location, quality, scale 1-10)
SLEEP (Pattern, remedies)
NEUROLOGICAL (LOC, orientation, PERRL, memory, numbness, tingling, tremors, Glasgow Coma Scale, sensation)
Narrative Assessment
Pathophysiology
Serum drug levels:
NANDAs
Fatigue
Activity intolerance
Mobility, impaired
Diversional activity deficit
Peripheral neurovascular
dysfunction
Sleep disturbance
Thought process, altered
Disuse syndrome
Memory, impaired
Confusion, acute/chronic
Infant behavior
Knowledge deficit R/T
Non-compliance
Pain, acute/chronic
X-rays:
EEG:
NS V40 Client Care Plan
NANDAs
4
Rev. 8/2005
Solitude and Social Interaction
Data Gathering/Diagnostic Tests
Special senses exam, discomfort, communication, sexuality, menses, vaginal drainage (lochia), breast, fundus of uterus, history of
pregnancy
Social skills, coping skills assets and strengths, communication content and speech pattern
Narrative Assessment
Pathophysiology
NANDAs
Thought process, altered
Sensory perceptual alteration
Impaired verbal communication
Sexual dysfunction
Knowledge deficit R/T
Non-compliance
Hazards
SUBSTANCE ABUSE (Specify level of use)
SAFETY (Restraints)
Data Gathering/Diagnostic Tests
Narrative Assessment
Blood alcohol:
Drug levels:
Developmental SCR
Data Gathering/Diagnostic Tests
Erickson’s Stage:
Pathophysiology
Ineffective individual coping
Ineffective family coping
Risk for self-mutilation
Non-compliance
Knowledge deficit R/T
Developmental tasks, adjustments related to aging, parenting behaviors, experiences that impact human development, grieving process
Weight (pounds/kilograms and percentile), length/height (inches & percentile), head circumference (inches & percentile)
Narrative Assessment
Pathophysiology
(Maturational/Situational, Physical &
Cognitive)
Describe DSCR task:
NS V40 Client Care Plan
NANDAs
5
NANDAs
Growth & development, delayed
Parenting, altered, potential for
Coping, family, altered/ineffective
Conflict, parental
Role performance, altered
Knowledge deficit R/T
Situational low self-esteem
Rev. 8/2005
NS V40 – Part A
Nursing System: No. 1 Prioritized Nursing Diagnosis
Assessment
Identify which self-care
requisite you are working on:
USCR, DSCR, HDSCR
Client Goals,
Desired Outcomes,
Time Frame
Nursing Responsibilities
Rationale
Evaluation
Effectiveness of Nursing
Interventions:
Goal Accomplished?
Check one:
Yes
Partially
No
Suggested Revisions:
NS V40 Client Care Plan
6
Rev. 8/2005
NS V40 – Part A
Nursing System: No. 2 Prioritized Nursing Diagnosis
Assessment
Identify which self-care
requisite you are working on:
USCR, DSCR, HDSCR
Client Goals,
Desired Outcomes,
Time Frame
Nursing Responsibilities
Rationale
Evaluation
Effectiveness of Nursing
Interventions:
Goal Accomplished?
Check one:
Yes
Partially
No
Suggested Revisions:
NS V40 Client Care Plan
7
Rev. 8/2005
NS V40 – Part A
Nursing System: No. 3 Prioritized Nursing Diagnosis
Assessment
Identify which self-care
requisite you are working on:
USCR, DSCR, HDSCR
Client Goals,
Desired Outcomes,
Time Frame
Nursing Responsibilities
Rationale
Evaluation
Effectiveness of Nursing
Interventions:
Goal Accomplished?
Check one:
Yes
Partially
No
Suggested Revisions:
NS V40 Client Care Plan
8
Rev. 8/2005