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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