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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

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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

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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:

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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