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Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Student Name: _________________________

Clinical Site: _________________ Date: ___________

Patient Initials:
Primary Diagnosis:

Primary Doctor:

Age:
Code Status:
Sex:
Admission thru: __ Direct Admit __ ER

Past Medical History:

__ Transfer from another hospital


__ Transfer from another unit
__ Other ________________________________

Past Surgical History:

Pt from: __ Home
__ Long-term care Facility
__ Psychiatric Facility
__ Skilled Nursing Facility

Consults:

Admission Date:

Ht:

Wt:

Allergies:

Vital Signs:
Temp (+ route) _____ Pulse _____ BP _______ Respirations ______ O2 Sat ______ Pain level ______
Diet: ____________________________ Accucheck(s): __________ ___________ ____________ __________

Data Collection
Neurological (include pain, mental status, speech)

Cardiac

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Special
Equipment

Interventions

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

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Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Psychosocial

Site

Gauge

Start
Date

Examination

Intervention(s)

Intravenous Lines (IVs)

IV solution:

Rate:

Laboratory Studies and Diagnostics


Test

Date

CBC
Hemoglobin
Hematocrit
Platelets
RBCs
WBCs
ESR
HgA1c
BMP,CMP
Glucose
Electrolytes
BUN Albumin
Creatinine
T3, T4, TSH

ABGs
pH, PaCO2
HCO-3
PTT,PT/INR
Platelets

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Patients results

Why does this


patient have this
value?
What does this mean
for your patient?

What care or
considerations will you
implement?

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Drug Levels
Digoxin
Vanco
Dilantin
Theophylline
Cardiac
Markers
Troponin
Myoglobin
CK-MB, BNP
EKG
Liver
Function
ALT, AST
Amylase
Lipase,
CHOL,
TriglyceridesL
DL, HDL
Urinalysis

Cultures
Wound
Urine
Throat
Blood
X-ray
Reports
CT and/or
MRIs

Ultrasound
Echo/Other

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Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Operative Reports

Morse Fall Scale

Item
1. History of falling;
immediate or within 3
months
2. Secondary diagnosis
3. Ambulatory aid
Bed rest/nurse assist
Crutches/cane/walker
Furniture
4. IV/Heparin Lock
5. Gait/Transferring
Normal/bedrest/immobi
le
Weak
Impaired
6. Mental status
Oriented to own ability
Forgets limitations
Total

Scale
No 0
Yes 25
No 0
Yes 15
0
15
30
No 0
Yes 20

Action

0
10
20

0
15
Risk Level
Low Risk

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(Hospital)

ScoringMFS Score

0 - 24

Moderate
Risk

25 - 50

High Risk

51

Good Basic
Nursing
Care
Implement
Standard
Fall
Prevention
Intervention
s
Implement
High Risk
Fall
Prevention
Intervention
s

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Hendrich II Fall Risk Model (Rehab/LTC)

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Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Braden Skin Risk Scale


Sensory
Perception

1.

2.

3.

4.

Completely
Limited

Very Limited

Slightly
Limited

No
Impairment

1.

2.

3.

4.

Constantly
Moist

Very Moist

Occasionally
Moist

Rarely Moist

1.

2.

3.

4.

Bedfast

Chairfast

Walks
Occasionally

Walks
Frequently

1.

2.

3.

4.

Completely
Immobile

Very Limited

Slightly
Limited

No
Limitations

1.

2.

3.

4.

Very Poor

Probably
Inadequate

Adequate

Excellent

1.

2.

3.

Problem

Potential
Problem

No Apparent
Problem

Moisture

Activity

Mobility

Nutrition

Friction
and Shear

Indicate Score:

Total Score
NOTE: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.
(15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk)
CopyrightBarbaraBradenandNancyBergstrom,1988

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Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Medications
Allergies: __________________________________ Medication Times: _________, _______ , ____________

Name of
Medication
Brand and
Generic

Check VS
Check Pain Level
Indication and
Dose
Pharmacological
and
class
route

Name of
Medication
Brand and
Generic

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Indication and
Pharmacological
class

Dose
and
route

Check appropriate labs


Check Blood Glucose
Safe?
Possible Side Effects
Nursing Considerations
Y/N
(All common and serious.
for THIS medication
Min 1 for each system)
(Assessment data, labs,
follow up)

Safe?
Y/N

Possible Side Effects


(All common and serious.
Min 1 for each system)

Nursing Considerations
for THIS medication
(Assessment data, labs,
follow up)

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Nurses Notes
STC-04-04- 2016

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Date/Time

Notes

Signature

Nurses Notes
Date/Time

STC-04-04- 2016

Notes

Signature

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Intake and Output


PO Intake
Breakfast

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Enteral
Intake
Time

Amount
(ml)

IV Intake
Time

Amount
(ml)

Output
Time

Type

Amount (mL)

BM
Time

Type

Amount
(mL)

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

Urine
Emesis

Consumed
________%
Fluids
_______ mL

Liquid
Formed
Colostom
y

Drain

Lunch
Consumed
________%
Fluids
_______mL

Urine
Emesis

Liquid
Formed
Colostom
y

Drain

Dinner
Consumed
________%
Fluids
_______mL

Urine
Emesis

Liquid
Formed
Colostom
y

Drain

HS snack
Consumed
________%
Fluids
_______mL

Urine
Emesis

Is this patient
receiving enteral
nutrition?
Yes
No

Urine
Emesis

Liquid
Formed
Colostom
y

Drain

Liquid
Formed
Colostom
y

Drain

Type
_________________
_________________

Tubing Change:
_________

Urine
Emesis

Liquid
Formed
Colostom
y

Drain

Total

Total

Total

* If patient is incontinent, please note whether the void was scant, moderate, or copious.
* Measure all Foley Catheter output (once a shift unless more often is necessary).
* Measure all drain output (once a shift).
* Measure liquid stools and emesis when able to contain

New Orders
1.
2.
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Total

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

3.
Nursing Diagnoses
Nursing Diagnosis:
#1.

1.

Goal:

Interventions:
1. (Assess)

2.

2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)

#2.

1.

1. (Assess)

2.

2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)

STC-04-04- 2016

Care Plan Data Collection

(Must be complete by post conference to earn a satisfactory clinical grade for the day)

#3.

1.

1. (Assess)

2.

2. (Do)
3. (Collaborate)
4. (Medication)
5. (Safety)
6. (Teach)

STC-04-04- 2016