Professional Documents
Culture Documents
SCHOOL OF NURSING
CARE PLAN DATA SHEET
NURSING PROCESS
Student Name_____________________________________ Course_________________________________ Date________________________
Assessment
Additional Notes:
_____________________________________________
Cultural/Ethnic: _____________________________________________
_____________________________________________
_____________________________________________
2. Medical Data:
Reason for hospitalization: ____________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Assessment Tool
Nursing Diagnosis
____________________________________________________________________________________________________________________
Laboratory test results only for abnormal results. Please indicate why they are abnormal also indicate the norms and what the norm
results indicate.
Lab Test Performed
Why Abnormal
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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Use the Assessment Tool in head-to-toe format and record information for both the physical and functional assessment data.
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Data Collection
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Vital Signs
T_______ P_______ R_______ BP_____/____
HT_______WT_______
_____________________________________
Head and Neck:
_____________________________________
Mental Status: ______________________________________________________________________
Scalp:
_____Clear
_________________________________________
_____Dry
_________________________________________
_____Other__________________________________________________________________
_____________________________________
Hair:
_____Clean
_________________________________________
_____Dirty
___________________________________________
Face:
_____Symmetrical
___________________________________________
Assessment Tool
Nursing Diagnosis
_____Asymmetrical
Eyes:
Neck:
___________________________________________
___________________________________________
_____Neck distention
___________________________________________
_____Tender
___________________________________________
_____large palpable lymph nodes
___________________________________________
Ears:
_____No drainage/lesions
___________________________________________
Mouth:
Gums:
_____Moist, pink
___________________________________________
_____Pale
___________________________________________
_____Inflamed
___________________________________________
_____Bleeding
___________________________________________
_____Ulcers
___________________________________________
Teeth:
_____Pallor
___________________________________________
_____Lesions present
___________________________________________
_____white patches
___________________________________________
_____Dental Caries
___________________________________________
___________________________________________
Assessment Tool
_____Dry
Self Care:
Nursing Diagnosis
___________________________________________
______________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
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_____Pain present_________________________________________________
(Specify level of pain, scale of 1-10)
___________________________________________
___________________________________________
__________________________________________
Self-Perception/Self Concept:
What is expected for a patient of this age? __________________________________________
___________________________________________
___________________________________________
Safety: Physical/Mechanical/Microbial/Chemical:
______________________________________
__________________________________________
__________________________________________
__________________________________________
_____Visual deficits
__________________________________________
Assessment Tool
Nursing Diagnosis
__________________________________________
Cardiovascular:
Heart Sounds: Clear
S1
S2
S3
>3secs (Amount)
__________________________________________
Respiratory:
Chest Expansion: Symmetrical/ Asymmetrical
R Breath Sounds: Clear Abnormal/Explain L Breath Sounds: Clear Abnormal/Explain:
_____________________________________________________________
Retractions: Mild
Moderate
Severe Intercostal
Subcostal
__________________________________________
Sternal Substernal
Dyspnea/Orthopnea/Apnea/Tachypnea
moderate,
Tubes/site/location
Nasal Flaring
heavy
Drains/site/location (circle)
Integumentary:
Skin: Intactness
__________________________________________
Assessment Tool
Nursing Diagnosis
_________________________________________
_________________________________________
_________________________________________
_____Pinched-up skin returns immediately to original position, elastic _____Pinched-up skin takes >=30 seconds to return to original position, inelastic
Infestations:
_____None
_________________________________________
_____Present____________________
Nails:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_____Other: ___________________________________________________________
_________________________________________
Digestive/Gastrointestinal/Nutrition:
Size and contour of abdomen:
_____________________________________
_____________________________________
_____Flat/soft/firm
_____Distended
_____Enlarged
_____Tender
_________________________________________
______________________________________
Bowel sounds on auscultation in all 4 quadrants (for up to 5 minutes in each quadrant)
Frequency and characteristics: _____________
__________________________________________
__________________________________________
_____Hypoactive_____________________________quadrant____________________
__________________________________________
_____Absent________________________________quadrant____________________
__________________________________________
___________________________________________
Assessment Tool
Nursing Diagnosis
___________________________________________
___________________________________________
Diet: _______________%Eaten______________Snacks_____No_______Yes______
___________________________________________
___________________________________________
Factors that may alter nutritional intake less or more than body requirements:
___________________________________________
_____________________________________________________________________
Specify factors
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
____________________________________________________________________________________________________________________
Assessment Tool
Nursing Diagnosis
Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?
1.
Related to:
Evidenced by:
Assessment Tool
Nursing Diagnosis
Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?
2.
Related to:
Evidenced by:
Assessment Tool
Nursing Diagnosis
Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?
3.
Related to:
Evidenced by:
10
Assessment Tool
Nursing Diagnosis
Dosage and
Frequency of
Administration
Classification
Common Side-Effects
11
Assessment Tool
Nursing Diagnosis
Instructor Signature
Date Observed
12
Assessment Tool
Nursing Diagnosis
13