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    Adult and Elder I. Nursing Care Plan

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    teresapaz
    This document provides a template for a nursing student's clinical documentation on their second clinical day. It includes sections for demographic data, subjective and objective assessments, review of systems, vital signs, and standardized tools. The goal is to gather relevant information about the patient's medical history, current symptoms, and physical exam findings to develop an individualized nursing care plan.

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    Adult and Elder I. Nursing Care Plan

    Uploaded by

    teresapaz
    149 views6 pages
    This document provides a template for a nursing student's clinical documentation on their second clinical day. It includes sections for demographic data, subjective and objective assessments, review of systems, vital signs, and standardized tools. The goal is to gather relevant information about the patient's medical history, current symptoms, and physical exam findings to develop an individualized nursing care plan.

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    Adult and Elder I. Nursing Care Plan NYU

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    This document provides a template for a nursing student's clinical documentation on their second clinical day. It includes sections for demographic data, subjective and objective assessments, review of systems, vital signs, and standardized tools. The goal is to gather relevant information about the patient's medical history, current symptoms, and physical exam findings to develop an individualized nursing care plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    149 views6 pages

    Adult and Elder I. Nursing Care Plan

    Uploaded by

    teresapaz
    This document provides a template for a nursing student's clinical documentation on their second clinical day. It includes sections for demographic data, subjective and objective assessments, review of systems, vital signs, and standardized tools. The goal is to gather relevant information about the patient's medical history, current symptoms, and physical exam findings to develop an individualized nursing care plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    CLINCAL DAY #2

    NEW YORK UNIVERSITY COLLEGE OF NURSING ADULT AND ELDER 1 (NURSE-UN.0240) NURSING CARE PLAN Students Name: Date of Patient Care: Demographic Data: Patients Initials: Allergies/Reaction: Age: Gender: Date of Admission: DNR/DNI Status: Advance Directives: Y/N Clinical Unit: Clinical Instructor:

    ASSESSMENT
    SUBJECTIVE DATA Reason for Seeking Care (What brought you to this hospital?): Past History Medical (Include date condition was diagnosed, if known): High blood pressure Depression Asthma Heart attack Anemia Diabetes Stroke Cancer Seizures

    CLINCAL DAY #2

    Deep vein thrombosis Thyroid disease

    Kidney failure Arrhythmia

    Arthritis Others

    Surgical (Include dates of surgery, if known): Date Type of Surgery

    Mental Health: Any mental conditions such as depression and anxiety Any history of eating disorder Any history of taking medications or received treatment for psychiatric condition Yes or No Yes or No Yes or No

    CLINCAL DAY #2

    Psychosocial/Family: Religion Cultural/Ethnic background Marital status Support system/caregiver Living arrangement Others (Smoking, Alcohol use, etc.)

    Review of Systems (Put an X to all that apply): Overall Health Status Good Neurological/Special Senses Dizziness Seizures Vision loss Other: Weakness Blurred vision Decreased hearing Tremors Double vision Ringing in ears Fair Poor

    CLINCAL DAY #2

    Respiratory Cough Other: Cardiovascular Chest pain Other Gastrointestinal Abdominal pain Constipation Genitourinary/Reproductive Painful urination Difficulty voiding Skin Dryness Suspicious lesion Itching Other: Rash Blood in urine Urinary incontinence Sexual dysfunction Other: Nausea Tarry stools Vomiting Bloody stools Diarrhea Other: Edema Palpitation Wheezing Bloody sputum Shortness of breath

    CLINCAL DAY #2

    Pain (PQRST) Y/N. If yes, address: Provocative/Palliative (What makes it worse/better?) Quality (Describe your pain) Region/Radiation (Can you show/point to me where it is?) Severity (Numeric/Faces scale) Timing (When did it start, How long does it last, Does it come and go, etc..)

    OBJECTIVE DATA General Survey Physical Appearance:

    Body Structure:

    Mobility:

    Behavior:

    CLINCAL DAY #2

    Environmental/Situational Survey: (IV, Oxygen, Cardiac Monitor; Safety and Cleanliness):

    Vital signs BP: Pulse Rate (Apical): Pulse Rate (Radial): Respiratory Rate:

    Temperature/Route: Height: Weight:

    SpO2:

    Tools (Score and Implications) download from Blackboard Braden

    Hendricks

    Katz

    Pneumonia/Flu Screening Form

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