Measurable Outcome Nursing Orders/Action Include Rationale &amp References Evaluate Each Outcome Criterion &amp Make Recommendations.

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TROY UNIVERSITY BSN PROGRAM
Patient-Centered Care Plan
Student’s Name:_________________________________ Age:______ Sex:_____ Room No. ________
Patient’s Initials:_________________________________ Long-term Goal: ______________________
Medical Dx: _____________________________________ ____________________________________
Surgical Dx: _____________________________________ ____________________________________
Admitting Dx:_____________________________________ ____________________________________

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

TROY UNIVERSITY BSN PROGRAM
Patient-Centered Care Plan
Student’s Name:_________________________________ Age:______ Sex:_____ Room No. ________
Patient’s Initials:_________________________________ Long-term Goal: ______________________
Medical Dx: _____________________________________ ____________________________________
Surgical Dx: _____________________________________ ____________________________________
Admitting Dx:_____________________________________ ____________________________________

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

TROY UNIVERSITY BSN PROGRAM
Patient-Centered Care Plan
Student’s Name:_________________________________ Age:______ Sex:_____ Room No. ________
Patient’s Initials:_________________________________ Long-term Goal: ______________________
Medical Dx: _____________________________________ ____________________________________
Surgical Dx: _____________________________________ ____________________________________
Admitting Dx:_____________________________________ ____________________________________

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

ASSESSMENT ANALYSIS PLAN
IMPLEMENTATION EVALUATION
Data Collection
Subjective & Objective Nursing Diagnosis Patient-centered Goals
Measurable Outcome Nursing Orders/Action Include Rationale & References Evaluate Each Outcome Criterion & Make Recommendations

1. M.L. (Mary) is a very thin 80 year old woman who after recently moving in with her
daughter broke her left hip after tripping over her dog. The hip was surgically repaired
three days ago. On exam she has a 4 inch incision noted to left trochanter with small
amount of serosanguinous drainage on dressing. There is a small amount of erythema to
the incision line. Due to some post-surgery confusion, her recovery is slower than usual
for a patient following this particular surgery. She has an IV of Normal Saline at
125cc/hr. IV site with no redness or swelling. Foley Catheter to bedside drainage bag.
Urine output the last 24 hours has been 720. SCD’s (sequential compression devices) to
both legs. There are numerous bruises to her arms from hitting the bedrails and from the
initial fall. When nurse asks patient her name. patient responds by saying “Sara”. Patient
has hx of diabetes, and hypertension.
Vital Signs: 0800 BP 155/100 P 96 R 22 Temp 99.0AX . Pain scale: Patient states
“hurts” and does not allow you to touch it.
1200 BP 167/98 P 100 R 24 Temp 99.2AX Pain: “hurts”
Blood Sugar 7 am 309mg/dl
11 am 244mg/dl
Physician Orders
NS @60cc/hr
Clear Liquids
Morphine Sulfate 4mg IV q4 hours for pain as needed
Phenergan 25mg IV every 4 hours for nausea as needed
Patient to ambulate TID with physical therapy
Clean incision BID with saline
Docusate Sodium po daily
FSBS 7,11,4, 9
Humulin R 5units bid
Lab Work:
Hematology
Test Normal Abnormal Reference Range
CBC
WBC 12.9 4.8-10.8
RBC 4.49 4.2-5.4
Hemoglobin 13.7 12-16
Hematocrit 40.4 37-47.0%
CP-7
Basic Metabolic Panel
Sodium, serum 133 136-145mmol/L
Potassium, serum 3.8 3.5-5.1mmol/L
Glucose 309 70-110mg/dl
BUN 11 7-18mg/dl
Creatinine .7 06-1.3mg/dl
UA
Color yellow Yello/-straw
Clarity clear clear
Glucose norm norm
Ketone neg neg
Nitrites neg neg
Leukocytes 100 neg
Blood neg neg
WBC ua 10-15 none
RBC none none
2. P.P. is a 68 year old Jehovah Witness was admitted last week after experiencing a
massive heart attack. Although his eyes are open, he does not respond to external stimuli.
Because of impaired swallowing, a feeding tube has been placed to ensure adequate
nutrition and hydration. The feeding tube is to his left nare and has Jevity at 30cc/hr
infusing. Last residual checked after 4 hours was 60cc. His oral mucous membranes and
lips are dry and crusty. He is unable to position himself. On exam there is an area of
nonblanchable erythema to his sacral area. An IV of Normal Saline is running at
125cc/hr to his right antecubital. IV site with some bleeding and swelling at site. He is
incontinent of urine and stool. A foley catheter was placed with some difficulty due to pt
having a hx of prostate CA without receiving any treatment. The foley catheter is
draining cloudy, yellow urine. Son states his father would never want to have to be taken
care of in this way. Son cries frequently when at his father’s bedside.
Vital Signs: 0800 BP 110/60 P 92 R 20 Temp 99.9AX
Pain Scale: Grimaces when turned in bed.
1200 VS BP 96/62 P 100 R 22 Temp 99.2AX
Pain Scale: Grimaces
Physician Orders:
Jevity at 30ml/hr
NPO
Normal Saline 125ml/hr
Foley catheter
Turn q2
HOB up 30 degrees or more
Lab work:
Hematology
Test Normal Abnormal Reference Range
CBC
WBC 14.7 4.8-10.8
RBC 4.0 4.2-5.4
Hemoglobin 11.9 13-17
Hematocrit 36 40-54%
CP-7
Sodium, serum 137 136-145mmol/L
Potassium, serum 3.3 3.5-5.1mmol/L
Bun 19 7-18mg/dl
Creatinine 0.7 0.6-1.3
UA
Color amber yellow-straw
Clarity clear clear
Leukocytes 150 neg
Blood 200 neg
WBC 20-30 none
RBC 5-10 none
3. D.L. is an 87 year old woman who underwent an ORIF of a left hip fracture 2 days
ago. She fell at home and was transported to the hospital. She underwent surgery the
next day. She moved from Italy to join her grandson and his family only 2 months ago
and she speaks very little English. All information was obtained through her grandson.
Her last bowel movement was 5 days ago prior to her surgery. Her VS are stable; she has
an IV of D51/2NS with 20meq KCL at 100ml/h. She has an IV site with small amount of
bleeding no swelling and 3 L O2 per NC (nasal cannula). Prior to surgery she was
ambulating independently. She is to begin working with physical therapy today. Foley
Catheter to drainage bag with dark yellow urine about 100ml in bag.
Vital Signs: 0800 BP 106/62 P 108 R 24 Temp 99 oral. SPO2 96% Pain Rates 8 on
scale 0-10 when asked by grandson
1200 Vital Signs BP 120/68 P 110 R 22 Temp 98.9 oral SPO2 97% Pain 8 on scale 0-10
when asked by grandson
FSBS 0800 79mg/dl
1200 101mg/dl
Physician Orders:
D5 ½ NS with 20 meq KCL at 100ml/hr
Foley catheter
NPO
FSBS every 4 hours
Zofran 4mg every 4 hours as needed for nausea
Lab work:
Hematology
Test Normal Abnormal Reference Range
CBC
WBC 11.1 4.8-10.8
RBC 3.9 4.2-5.4
Hemoglobin 9.6 12-16
Hematocrit 30 37.0-47.0%
Platelets 200 130-400
CP-7
Sodium 142 136-145mmol/L
Potassium 3.0 3.5-5.1mmol/L
Glucose 220 70-110mg/dl
BUN 20 7-18mg/dl
Creatinine 1.5 0.6-1.3
UA
Color dark yellow-straw
Clarity cloudy clear
Leukocytes 150 neg
Blood pos neg
WBC 20-30 none
RBC 5-10 none
4. A.B. an 18 year old woman presents at the ED with severe L flank and abdominal
pain, and N/V. S.R. looks very tired, her skin is warm to touch and she is perspiring. She
paces about the room doubled-over and is clutching her abdomen. A.B. tells you that the
pain started early this morning and has been pretty steady for 2 hours. Her abdomen is
soft and without tenderness, but her L flank is extremely tender to touch/palpation. She
is obviously in a great deal of pain. Rates pain 10 on scale 0-10. You place her in one of
the exam rooms and take the following VS: 138/88, 90, 20. 99F, Pain score of 10 on a 0-
10 pain scale.
Vital Signs: 1 hour after arrival BP 123/87 P- 96 R- 16 Temp 99.3. Pain 8 on scale 0-
10.
A flat plate x-ray of the abdomen and an intravenous pyleogram (IVP) confirm the
diagnosis of a kidney stone low in the L ureter.
Physician Orders:
NPO
Normal Saline 500ml/hr
Demerol 25mg IV every 4 hours as needed for pain
Phenergan 12.5mg IV every 4 hours as needed for nausea
Toradol 30mg IV now
Strain all urine
Lab work:
Hematology
CBC Normal Abnormal Reference Range
WBC 12.5 4.8-10.8
RBC 4.2 4.2-5.4
Hemoglobin 11 12-16
Hematocrit 35 37.0-47.0%
CP-7
Sodium 142 136-145mmol/L
Potassium 4.2 3.5-5.1mmol/L
Glucose 101 70-110mg/dl
BUN 20 7-18mg/dl
Creatinine 1.5 0.6-1.3
UA Normal Abnormal Reference Range
Color amber Yellow-straw
Clarity cloudy clear
Glucose Norm norm
Ketones neg neg
SG 1.030 1.003-1.030
Blood pos neg
Nitrites pos neg
Leukocytes 500 neg
WBC 25-30 none
RBC 15-20 none
Squa Epithelial TNTC none
5. Q. T. is a 76 year old widow who has recently become a resident of an extended care
facility. Just prior to admission she underwent surgery for removal of cataracts and
removal of her left big toe. Her children were concerned about her physical safety and
urged her to move into a nursing home. Several days after admission the client is
confused and withdrawn. Bruises are noted to her arms and legs. Client states “I don’t
know what happened.” “I am afraid of all these strange things.” She had multiple falls at
home prior to her hospitalization. Pt has hx of high blood pressure, diabetes, and
frequent urinary infections. On assessment her left big toe has some serosanguinous
drainage around the sutures. There is mild erythema and tenderness around her incision.
Vital signs: 0800 Temp 98.6 , Pulse 88, Respirations 18, BP 178/64
Pain-Unable to rate, grimaces and withdraws foot when left toe is touched.
1200 Temp 99, Pulse 92, Resp 18, and BP 166/80
Pain – grimaces when left toe is touched
Physician Orders:
2000 cal ADA diet
Daily Blood Sugars
Insulin 70/30 25units in AM SQ
Norvasc 10mg daily PO
Clonidine .1mg hs PO
Levaquin 500mg po daily
Sterile dressing changes daily
Lab Work
Normal Abnormal Reference Range
CBC
WBC 11.1 4.8-10.8
RBC 3.9 4.2-5.4
Hemoglobin 14 12-16
Hematocrit 36 37.0-47.0%
Platelets 200 130-400
CP-7
Sodium 142 136-145mmol/L
Potassium 4.2 3.5-5.1mmol/L
Glucose 220 70-110mg/dl
BUN 20 7-18mg/dl
Creatinine 1.5 0.6-1.3
UA
Color yellow yellow-straw
Clarity cloudy clear
Glucose >1000 norm
Ketones neg neg
SG 1.032 1.003-1.030
Blood neg neg
Leukocytes pos neg
WBC 5-10 none
6. L.M. is a 73 year old male has been admitted to the floor with a diagnosis of CVA
(cerebrovascular accident) that has caused weakness to the right side of his body. He is
unable to grasp with his right hand, which is his dominant hand. He is only able to
elevate his right arm and right leg about an inch off of the bed. He is unable to ambulate
or turn himself. He has an area of blanchable erythema to his right hip. He can use the
urinal with assistance. His speech is slurred but he is alert and oriented x3. He becomes
strangled at meal times and has to be fed slowly and with soft food. Over the 2 days, he
has developed a productive cough and has bilateral crackles on auscultation. Normal
saline at 75ml/hr is infusing to his left arm without redness/ swelling at site.
Vital Signs: 0800 BP 176/99 P 88 R 24 T 97.6. Pain 0
1200 BP 157/88 P 90 R 22 T 99 Pain 2 in chest with coughing
Physician Orders
Normal saline 75ml/hr
Vital signs q4 hours
Turn q2 hours
Physical Therapy for strengthening BID
Soft Mechanical Diet
I’s & O’s q shift
Chest xray
Lab Work:
Test Normal Abnormal Reference Range
CBC
WBC
11.9 4.8-10.8
RBC 4.49 4.2-5.4
Hemoglobin 13.7 12-16
Hematocrit 40.4 37-47.0%
CP-7
Basic Metabolic Panel
Sodium, serum 133 136-145mmol/L
Potassium, serum 3.8 3.5-5.1mmol/L
Glucose 122 70-110mg/dl
BUN 11 7-18mg/dl
Creatinine .7 06-1.3mg/dl
UA
Color yellow Yello/-straw
Clarity clear clear
Glucose norm norm
Ketone neg neg
Nitrites neg neg
Leukocytes neg neg
Blood neg neg
WBC ua none none
RBC none none
7. D.T.is a 24 year old African American female that suffered a spinal cord injury
causing paralysis below the level of the fifth and sixth thoracic vertebra. She is alert and
oriented x3. An IV of normal saline is to her right forearm. Some mild redness is noted
at the site. She has a tracheostomy tube with large amounts of thick yellow sputum. On
exam she has crackles bilaterally. As you assist her in turning you notice a quarter size
blanchable reddened area to her right hip. Foley Catheter intact with clear yellow urine
in drainage bag. No bowel movement in 5 days.
Vital Signs:0800 BP-120/70, Resp 22, Pulse 101, Temp 99, O2 sat 87%
Pain 2 on scale 0-10. (IV site)
Vital signs 1200 BP 133/68, Resp 24, Pulse 102, Temp 99.2, O2sat 86%
Pain 4 on scale 0-10 (headache)
Physician Orders:
2200 cal ada diet
Physical therapy TID
NS 75ml/hr
FC
Demerol 25mg IV q4 hours prn for pain
Phenergan 12.5mg IV q4 hours prn for nausea
Colace 100mg po bid
Lab Work:
Test Normal Abnormal Reference Range
CBC
WBC 10.9 4.8-10.8
RBC 4.49 4.2-5.4
Hemoglobin 13.7 12-16
Hematocrit 40.4 37-47.0%
CP-7
Basic Metabolic Panel
Sodium, serum 140 136-145mmol/L
Potassium, serum 3.8 3.5-5.1mmol/L
Glucose 112 70-110mg/dl
BUN 11 7-18mg/dl
Creatinine .7 06-1.3mg/dl
UA
Color yellow Yello/-straw
Clarity clear clear
Glucose norm norm
Ketone neg neg
Nitrites neg neg
Leukocytes 100 neg
Blood neg neg
WBC ua 10-15 none
RBC none none

Measurable Outcome Nursing Orders/Action Include Rationale &amp References Evaluate Each Outcome Criterion &amp Make Recommendations

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