Care Plan RN Progress Note 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 |
| Behavior | Participating Cooperative Guarded Withdrawn Isolative Avoiding eye contact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: |
| Speech | Coherent Incoherent Slurred Hyper Rapid Delayed Loud Yelling/Screaming Soft Mute Repetitive Non-Verbal |
| Psychotic
Symptoms |
NIA Hallucinations: Auditory Visual Tactile Olfactory Preoccupied Delusions: Somatic Paranoid Grandiose Persecution |
| Physical Problem | a None Cardiac Respiratory
GU No Pain a Pain (1-10) NO HURT HURTS HURTSMORE EVEN HURTSMORE WHOLE HURTSLOT WORSTHURTS 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: |
| Pain | |
| Medical Issues Addressed | Injuries: N/A yes Consults: N/A Yes Abnormal Labs: N/A. Yes
Tests: N/A Yes |
| Skin
Assessment |
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 |
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