PN2 2571 Care Plan 2023 - Rasmussen College
Nursing Clinical Packet
Patient Assessment and Care Plan
Instructions to student:
1) You must submit a minimum of two acceptable packets to pass your clinical. Each
packet is worth 35pts towards your Fundamentals course grade.
2) Please submit the packet electronically in your clinical course shell, then please
record your answers in bold or in a colored or lower case font. This helps us
identify your answers more quickly.
1
, PATIENT ASSESSMENT FORM
STUDENT NAME: Marina Marmolejo DATE: 2/8/2019
CLIENT ROOM # DOB:8/18/34 AGE : 84 GENDE ADMISSION DATE:
INITIALS: 124 R: F 1/25/15
JC
CODE ALLERGIES: N/A MARITAL OCCUPATION (FORMER):
STATUS: STATUS: Widow teacher
N/A
MEDICAL DIAGNOSIS (ES) ADMITTING CHIEF COMPLAINT :
forgetfulness
Dementia
PAST HISTORY (SURGERY/PROCEDURES) WITH DATES
N/A
ORDERS (current orders) RATIONALE (Why is this
ordered for this
client???)
EXAMPLE: 2 g Sodium diet with nectar thick Sodium is restricted due to
DIET liquids only edema in the bilateral lower
extremities and nectar thick
2
, liquids due to dysphagia
from a past stroke.
DIET regluar No difficulty swallowing
ACTIVITY Mobile No need for assistive
devices
I/O Q8 Check output once per
shift
VS Q8 Check vitals once per
shift
BLOOD daily General monitoring
GLUCOSE
FOLEY N/A
NG N/A
PEG/PEJ TUBE N/A
WOUND CARE N/A
RESPIRATORY Breathing treatments BID Shortness of breath
TREATMENT
TRACHEOSTOM N/A
Y
SUCTIONING N/A
CHEST TUBE N/A
SPECIAL N/A
EQUIPMENT
LAB ORDERS UA, CBC To monitor increasing
confusion
OTHER
REHAB ACTIVITY OR TREATMENT PLAN & RATIONALE
SERVICES SCHEDULE
PHYSICAL daily Increase activity
THERAPY
SPEECH N/A
THERAPY
OCCUPATIONA daily Increase ADL`s
L THERAPY
/ 1 pts
IVs (if applicable)
IV FLUID AND RATE: N/A SITE LOCATION AND CONDITION: N/A
LAST DRESSING CHANGE: N/A LAST TUBING CHANGE: N/A
3
Nursing Clinical Packet
Patient Assessment and Care Plan
Instructions to student:
1) You must submit a minimum of two acceptable packets to pass your clinical. Each
packet is worth 35pts towards your Fundamentals course grade.
2) Please submit the packet electronically in your clinical course shell, then please
record your answers in bold or in a colored or lower case font. This helps us
identify your answers more quickly.
1
, PATIENT ASSESSMENT FORM
STUDENT NAME: Marina Marmolejo DATE: 2/8/2019
CLIENT ROOM # DOB:8/18/34 AGE : 84 GENDE ADMISSION DATE:
INITIALS: 124 R: F 1/25/15
JC
CODE ALLERGIES: N/A MARITAL OCCUPATION (FORMER):
STATUS: STATUS: Widow teacher
N/A
MEDICAL DIAGNOSIS (ES) ADMITTING CHIEF COMPLAINT :
forgetfulness
Dementia
PAST HISTORY (SURGERY/PROCEDURES) WITH DATES
N/A
ORDERS (current orders) RATIONALE (Why is this
ordered for this
client???)
EXAMPLE: 2 g Sodium diet with nectar thick Sodium is restricted due to
DIET liquids only edema in the bilateral lower
extremities and nectar thick
2
, liquids due to dysphagia
from a past stroke.
DIET regluar No difficulty swallowing
ACTIVITY Mobile No need for assistive
devices
I/O Q8 Check output once per
shift
VS Q8 Check vitals once per
shift
BLOOD daily General monitoring
GLUCOSE
FOLEY N/A
NG N/A
PEG/PEJ TUBE N/A
WOUND CARE N/A
RESPIRATORY Breathing treatments BID Shortness of breath
TREATMENT
TRACHEOSTOM N/A
Y
SUCTIONING N/A
CHEST TUBE N/A
SPECIAL N/A
EQUIPMENT
LAB ORDERS UA, CBC To monitor increasing
confusion
OTHER
REHAB ACTIVITY OR TREATMENT PLAN & RATIONALE
SERVICES SCHEDULE
PHYSICAL daily Increase activity
THERAPY
SPEECH N/A
THERAPY
OCCUPATIONA daily Increase ADL`s
L THERAPY
/ 1 pts
IVs (if applicable)
IV FLUID AND RATE: N/A SITE LOCATION AND CONDITION: N/A
LAST DRESSING CHANGE: N/A LAST TUBING CHANGE: N/A
3
