Ivy Tech Community College of Indiana
Nursing Program – Region 6
Nursing Care Plan and Evaluation
Student: __ Instructor: _Date: _1-28-2010_____
1. The nursing care plan evaluation is based upon the application of criteria appropriate for the student’s skill set. 2.
All nursing care plans must be typed (Times New Roman, 12 point font). The nursing care plan form is available on Blackboard™ in each clinical course. 3. The grading rubric must be attached – last page of nursing care plan. 4. All relevant assessment tools used (physical, psychological, or psychiatric i.e. Braden Skin Assessment, Fall Risk) must be attached.
HIPAA (Health Information Privacy and Protection Act) mandates all health care providers protect patient privacy. Only information that the patient specifically releases may be shared with others. Only professional persons (students and instructors) involved in care are allowed access to the health care information. The student should be cautious about what information is shared verbally and with whom. If the student is approached for patient information by someone who purports to have authority, the best course of action is to refer that individual to the appropriate administrative personnel.
IVY TECH COMMUNITY COLLEGE OF INDIANA – REGION 6
NURSING HISTORY & PHYSICAL ASSESSMENT FORM
Student _________________________ Date of Care __1-26-2010 to 1-27______ Facility/Unit _Oncology_BMH___ Instructor
Patient's Initials _DH___ Age __79__ Gender__F__ Martial status: Widow__ DOB: _7/29/1930__________
Birthplace: Randolph County__ Ethnic origin/Race: _Caucasian_ Occupation: previous factory worker_
Work status : retired_________ Educational background __High school______________
History source initials ___Pt__ Relationship to client __self__________________
Transcultural Considerations: (Time, space, touch, & value orientation, language considerations, spiritual beliefs, education level)
Pt speaks English. High school was the highest education received. She worked at a factory for years and then quit to stay home and raise her two kids.
Reasons for Seeking Care: (Brief statement in patient's words that describes reason for visit - Chief Complaint) Pt states she is here due to her ovarian cancer.
Past Health History:
Approximate hospitalization dates:
Serious or Chronic Illnesses (Approximate onset):
Pt has a hx of: HTN, gallbladder disease, hiatal hernia, ulcers, diabetes type 2, hypothyroidism, depression, ovarian cancer, arthritis, migraines, cataracts and a right leg fx. Pt has also had these surgeries: hysterectomy, appendectomy, cataracts, cholecystectomy, colon resection, hernia, thyroidectomy, tonsillectomy, and adenoidectomy.
Current Obstetric Assessment:
Gravidity ______ Term ______ Preterm ______ Abortions ______ Living ______
Blood Type _____ Rh Factor _____
LMP _______ EDC _______ RhoGAM Status ______ DTR ________ (if applicable)
Date & Time of Delivery __________________________________
Type of Delivery ___ SVD ___ Forceps ____ Vacuum ____ Cesarean Section
___________ Anesthesia/Analgesia _______ EBL
Perineum: ______ Intact ______ Episiotomy _____ Laceration & Location__________________
Please note any current obstetrical problems/complications (GDM, pre-eclampsia, etc.)
Please note any past obstetrical problems/complications: (Condition, duration, treatment)
Apgar Score ___ / ___
Gestational Age _____weeks Cord Vessels_____
Feeding method ______ Weight at Birth...
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