Care plan in a template care map format
Medical diagnosis including patho physiology signs and symptoms diagnosis
and typical treatment
History and physical assessment from patient
Brief explaining of lab test and diagnostic test date, normal values
patient result rationale for other reason for abnormality
List of doctors order (nursing work list) including rational of why
order was written for patient.
Pharmacological intervention including name of medication name, dose
,route, frequency, classification, 3 of the top side effect and the
rationale for taking them.
Analysis of the assessment finding evidenced by correctly identifies the
priority physiologic psychosocial and educational diagnoses, recognizes
variant assessment findings. Comprehensive list of nursing diagnosis
Nursing diagnosis #1 Psychosocial, #2 Physiologic and #3 Educational
supported by relevant assessment finding, correctly states selected
nursing diagnosis (NANDA) including related to/as evidenced by. Goal is
written using SMART FORMAT .Outcomes are identified
I need 3 interventions. Interventions that will clearly support the
related goals. One EBP rationale per intervention that clearly supports
the intervention. Citation for each intervention written in APA format.
Evaluation of each intervention/patient education/discharge planning. I
need at least 3 references text,
The patient information is as follow:
History and physical Assessment:
NLN is a 64yr female with admitting diagnosis of septic knee, allergies,
levsin, latex, shrimp. Medical history include: Rheumatoid, Arthritis,
HTN, Hypothyroidism, TIA , GERD, Migraines, Prolapsed Valve, Total Right
Knee Replacement. Vital Signs 97.3 Pulse 68 Respiration 20 Blood
Pressures 106/55. O2 sat 95% RA. Patient is alert and oriented x3,
appropriate behavior, pupils equal, round, react to light. Moves all
extremities; equal strength bilaterally. Appears slightly anxious. Lungs
sound clear on auscultation. Heart sounds S 1 S2 no murmur. Skin warm,
dry; color with peripheral IV access on right forearm with D51/2
infusing @ 75ml/hr. Left knee surgery ankle swollen, complain of pain
when flexing the calf. +3 pitting edema on left knee surgery site.
Redness and swelling observed on left knee. Skin turgor good, Abdomen
sort non tender, active bowel sound. Last BM this morning
Lab tests and Diagnostic test.
CBC, CMP -done on 4/15/2013, RBC 4.11 L, (normal 4.35-5.6) MCV, 100.1
normal (80.0-10.0). MCH-33.3H normal (27.7 -33.1). for anemia.
Doppler done 4/16/13 to R/o DVT.
List of Doctor�s order :
Active ROM left knee hip, knee and ankle.
Vital Signs Q8hrs
Daily CBC, BMP.
Cold pack on inner/outer thigh
Dextrose 5% 1000ml IV 75ml/hr .
Docusate sodium 100mg 1 cap PO BID.
Penicillin G Pot 5ml 4000.000 unit 8ml IV Q4hr x 7days.
Hydrocodone 5/500 2tab PO QID �Pain.
Suggestions related to Nursing Diagnoses
Pain, Acute related to inflammation and swelling.
Mobility: Physical, impaired related to pain and swelling of joint.
Falls, risk for related to pain and swelling of joint.
Infection, Risk for
Knowledge, Deficient related to treatment regimen
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