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admin 2 min read Nursing

[Answered]: Client General InformationAge:Gender (Circle): Male/…

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Client General InformationAge:Gender (Circle): Male/ Female / Not mentioned Resuscitation status: Is the client culturally and linguistically diverse (CALD)? (Circle): Yes / NoIs the client Aboriginal and/or Torres Strait Islander? (Circle): Yes / NoClient Health HistoryReason for current admission (brief statement):Past Medical/ surgical history: (include duration or year of occurrence if available):Psychosocial history:Applied anatomy, Aetiology and Pathophysiology (relevant to this client)Client Health Status and Plan of care advisedOn admission (to ward and ED if applicable):Relevant physical assessment findings:Vital Signs:Blood tests:Other investigations: (include X-rays, imaging studies, ECG, EEG.)Initial Treatment Plan on admission:Oxygen/Medications/ IV Fluid orders (discuss their action, indication and contraindication briefly):Initial nursing care plan/ actions:Progress during care:Vital Signs trend on a 24-hour basis:Blood tests (mention changes to previous results + any new tests done):Other investigations: (include X-rays, imaging studies, ECG, EEG.)Treatment Plan (changes only):Changes in Oxygen/Medications/ IV Fluid orders:Changes in nursing care plan/ actions (Include rationale for the changes made and if there were any contraindications in relation to observations, investigations, or health assessment):At discharge (if the client is currently admitted, mention discharge plan): Discharge Education:Follow up advised:ReferralsCare Plan reviewReview the nursing care plan of the client from admission to current status. Analyse if the interventions carried out were effective or how the team could change them and explain briefly in the space given below. Discuss within a group/ or with your supervisor.

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