Plan of care
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A sample plan of care that can be use in different hospital setting to gather pertinent client information and planning your day.
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Plan of care
- 1. PLAN OF CARE Date: StudentName: Time Task Assessments neededand rational Outcome Patient1 Outcome Patient2 Outcome Patient3 0630 - 0720 Hand inresearch, checkkardex, MAR, progress notes,lastDr’s orders,clipboard and NN priorto report.Be aware of nightshift leavingandgiving verbal reportto days.Day partnerswill go overreport together. Who isyour priority patient? Numberpts basedon who will see 1st ,2nd , and 3rd . Alergies___________________ Code Status________________ IV _____________________ ml/hr Activity___________________ Diet______________________ Drains____________________ VS_______________________ Glucometer________________ Dressing___________________ Output____________________ 02 ________________________ LBM ______________________ Alergies___________________ Code Status________________ IV _____________________ ml/hr Activity___________________ Diet______________________ Drains____________________ VS_______________________ Glucometer________________ Dressing___________________ Output____________________ 02 ________________________ LBM ______________________ Alergies___________________ Code Status________________ IV _____________________ ml/hr Activity___________________ Diet______________________ Drains____________________ VS_______________________ Glucometer________________ Dressing___________________ Output____________________ 02 ________________________ LBM ______________________ 0730 RN: LPN: Take noteson all patients and notjust yours.Listen for data relayed. ReportInfo: ReportInfo: ReportInfo: 0745 Checkinwith instructorafter report. Determine prioritypt.,QPA, gluc.Look up meds. ABC,LOC, LOO, In,Outs, Pain,IV, Wound dressing, assessment, Abdominal, Chest,PVA, Neurovascular, Catheter, Drains Assessmentfindings: Assessmentfindings: Assessmentfindings:
- 2. 0830 - 0930 Setpt. up for morningcare, meds,Complete 24 hour flowsheet TIME ______________________ BP _____________________ HR _____________________ RR _____________________ O2 Sat __________________ T ______________________ TIME ______________________ BP _____________________ HR _____________________ RR _____________________ O2 Sat __________________ T ______________________ TIME ______________________ BP _____________________ HR _____________________ RR _____________________ O2 Sat __________________ T ______________________ 0930 Break 1000 Checkordersfor drainremoval and dressing changes,gather supplies.Assess for painand provide medsif necessary. Meds 1030 – 1130 Draft charting, Helpwiththe RN/LPN prnskills: Dressingchanges What didthe woundlook like? 1200 VS,glucs, reassessmentsof abnormal findings,Meds Reportoff to staff before leavingfor break. TIME __________ Reportabnormal BP ____________ O2 Sat ________ HR ____________ Temp ________ RR ____________ TIME __________ Reportabnormal BP ____________ O2 Sat ________ HR ____________ Temp ________ RR ____________ TIME __________ Reportabnormal BP ____________ O2 Sat ________ HR ____________ Temp ________ RR ____________ 1230 Break 1300 Make note of Ins and Outs(gets totaledat the end of shift@19) Do Ins/Outs balance? DRAINS TIME _____________ _____________ DRAINS TIME _____________ _____________ DRAINS TIME _____________ _____________ 1330 Complete Charting 2 minimum entriesper shiftincluding focused assessments
- 3. 1345 Kardex updates includingBM’s and erase outdatedinfo, update 48/6 1400 PostConference Didyou remove your medsigns? Reminders:cleanrooms and groom client,mouth care, QPA <10 mins, PVR per client,2V/S per client,organize,reviewmeds,practice. If yourpatientispost knee,the knee dressingmustbe de bulkedbefore physio(ideallyrightafteryourQPA).Thisisnota full dressingchange. Pt teaching: Hip Precautions NO bendingof the hip past90 NO crossingof the legsat the ankle/knee NO twistingthe bodyorlegs DO use a pillowbetweenthe legswhilelyingyourside Pt teaching: Knee Precautions- Don’t forgetCryo Cuff. NO squatting NO kneelingdirectlyonthe newjoint NO twisting NO pillowbehindthe knee Ptteaching:DB & cough, fluidinta
- 4. Labs and Meds: Pt: 1 Pt: 2 Pt:3 Labs: Meds: Labs: Meds: Labs: Meds: