How To Write A Clinical Nursing Care Plan
RN Program
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
NURSERY
STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/Nursery CLINICAL DATE: 01/20/15
PATIENT INTIALS: F.P. AGE: 9 days Sex: M RELIGION/CULTURE: Not documented
MATERNAL AND LABOR HISTORY: Mother was admitted to hospital on 01/09/15 for labor induction at 39 weeks and 4 days. Active labor began at 1015. F.P. was born at 1837. Mother is a heroin and methadone addict.
Growth/ Development F.P. weighed 6lb. 2 oz, 18 ½ inches.
Erickson:
Piaget:
LMP: 03/05/14 EDC: 01/12/15
Labor onset: date & time: 01/09/15 1015
ROM …show more content…
Head:
Head is symmetric and round. Skull is smooth and fused. Anterior fontanelle is soft, flat, open and diamond shaped. Posterior fontanelle is soft, flat and almost closed.
Hair:
Hair covers head. It is soft and light brown.
Face:
Cheeks are full and symmetrical. Facial features are symmetric.
Eyes: (sclera, pupils)
Sclera is white and pupils are equal, round and reactive to light. Small subconjunctival hemorrhage noted in right sclera.
Nose:
Nose is small and narrow with patent nares and intact septum.
Mouth:
Kips are symmetric, hard and soft palate is intact, very strong sucking reflex, free moving tongue and mucous membranes are pink and moist.
Ears:
Symmetrical, soft and pliable. Quick recoil when folded and released. Ears are in alignment with outer canthi of eyes.
Neck:
Neck moves freely in all directions. Creases are noted. Clavicles are straight and intact.
Chest: (breasts, nipples)
Barrel shaped chest. Nipples are symmetric. Lungs were clear when auscultated bilaterally. Normal breathing pattern.
Heart:
S1 and S2 sounds are heard clearly. HR is 146 bpm.
Abdomen: (Umbilicus, auscultation & percussion, femoral pulses, inguinal area,
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
NURSERY
STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/Nursery CLINICAL DATE: 01/20/15
PATIENT INTIALS: F.P. AGE: 9 days Sex: M RELIGION/CULTURE: Not documented
MATERNAL AND LABOR HISTORY: Mother was admitted to hospital on 01/09/15 for labor induction at 39 weeks and 4 days. Active labor began at 1015. F.P. was born at 1837. Mother is a heroin and methadone addict.
Growth/ Development F.P. weighed 6lb. 2 oz, 18 ½ inches.
Erickson:
Piaget:
LMP: 03/05/14 EDC: 01/12/15
Labor onset: date & time: 01/09/15 1015
ROM …show more content…
Head:
Head is symmetric and round. Skull is smooth and fused. Anterior fontanelle is soft, flat, open and diamond shaped. Posterior fontanelle is soft, flat and almost closed.
Hair:
Hair covers head. It is soft and light brown.
Face:
Cheeks are full and symmetrical. Facial features are symmetric.
Eyes: (sclera, pupils)
Sclera is white and pupils are equal, round and reactive to light. Small subconjunctival hemorrhage noted in right sclera.
Nose:
Nose is small and narrow with patent nares and intact septum.
Mouth:
Kips are symmetric, hard and soft palate is intact, very strong sucking reflex, free moving tongue and mucous membranes are pink and moist.
Ears:
Symmetrical, soft and pliable. Quick recoil when folded and released. Ears are in alignment with outer canthi of eyes.
Neck:
Neck moves freely in all directions. Creases are noted. Clavicles are straight and intact.
Chest: (breasts, nipples)
Barrel shaped chest. Nipples are symmetric. Lungs were clear when auscultated bilaterally. Normal breathing pattern.
Heart:
S1 and S2 sounds are heard clearly. HR is 146 bpm.
Abdomen: (Umbilicus, auscultation & percussion, femoral pulses, inguinal area,