Care plan  Essay Assignment Paper

Care plan  Essay Assignment Paper

Care plan  Essay Assignment Paper

care plan

RN Progress Note

Shift: D Day Evening
Orientation Person Place Time Situation
Cognition Alert Patient Asleep Disorganized Non-Verbal Concrete Thought Blocking

Poor Concentration Poor Judgment Confused Racing Thoughts Minimize Issuescare plan

Mood/Affect Appropriate Cheerful Bright Euphoric Neutral Agitated Hostile Irritable

Reactive Labile Fearful Anxious Sad Tearful Poor Motivation Hopeless Flat Blunted Restricted Patient Asleep Non-Verbalcare plan


Participating Cooperative Guarded Withdrawn Isolative Avoiding eye contact

Lethargic Crying Pacing Oppositional/Defiant Destroying Property Agitatedcare plan

Angry Outbursts Impulsive lntrusive Hyperactive Pressured Speech Resistive to Care Disorganized Sexually Inappropriate Verbally Aggressive Physically Aggressive Eyes closed Resting Harming Self by:   Other (specify):

Speech Coherent Incoherent Slurred Hyper Rapid Delayed Loud Yelling/Screaming Soft Mute Repetitive Non-Verbal


NIA Hallucinations: Auditory Visual Tactile Olfactory Preoccupied Delusions: Somatic Paranoid Grandiose Persecution
Physical Problem a None Cardiac Respiratory




Description of Pain: Dull Sharp Aching Burning Stabbing Shooting Other:

Aggravates Pain: Physical Activity D Sitting 13 Standing Walking O Other:

Effects of pain on daily-activities: Cl None Somewhat limiting Very limiting Interventions implemented«.

Medication administered within last 24 hours: Yes No

Educated patient on alternative interventions for pain management: Refused alternative options

Positioning Hot/Cold therapy Guided imagery Exercise/Stretching Deep breathing

Refocusing/Distraction Music therapy Modified environment Other:

Medical Issues Addressed Injuries: N/A yes Consults: N/A Yes Abnormal Labs: N/A. Yes

Tests: N/A Yes



No Wound Wound Description:  Location:

Wound Care:

Output GU: Normal Incontinent Urgency Dysuria

Gl: Bowel Movement: Yes No Normal Nausea Vomiting Diarrhea Constipation

Medication Compliant Non-Compliant

Side effects/Adverse drug reactions:

RN Teaching/ Education Coping Skills: Yes No Hand Hygiene: Yes No Health Issues: Yes No

Medication teaching provided to: Patient Parent Method: Handout 1:1 Instruction

Observation Level Q15 1:1 Line of sight
Precautions Suicide If currently on Suicide precautions, complete Daily Suicide Risk Assessment. If problem is newly identified, initiate suicide protocol and contact therapist.

Self-Harm Assault Homicide Elopement Seizure Fall Medical Risk

Arson Sexual Victimization Sexual Aggression NONE

Continue documentation on Backside

RN Signature: RN Date Time:

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