Daily plan of care

Nursing Students Student Assist

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Hello everybody. I have a question that I'm hoping I could get some direction or tips with. I'm a student LPN just about to finish my first semester. I just received my 'Care plan' scenarios that are to be handed in before my 'skills test'. I'm pretty good at the actual ADME part of the care plan scenarios but, I'm a little confused by, what the director of nursing calls " THE DAILY PLAN OF CARE ". I know about the structure but, I dont know about the components. I understand that is chronological and basic; a checklist of to do's. I just dont know what all the to do's are. If anyone could give me some pointers would be great.

This is what Im talking about

start shift:

QPA

Shift report

AM care

breakfast

Meds

I dont know what the other components there are to regular patient care. Any help is a appreciated.

Im not familiar with ADME, but here are some suggestion

Assessment

Labs

MD orders

Nursing interventions with goals and rationales

allergies (including type of rxt)

Code Status

multidisciplinary collaboration (will pt have PT, OT, RT?)

I/O

Specializes in Med-Surg, Orthopedics,Cardio,Geriatrics.

Where I work @ the VA we pass this out every morning to our patients before the start of shift when we are making rounds with the 7pm to 7am nurse going off duty with the 7am-7pm nurse coming on. Basically a daily plan of care is a document provided to the patient that outlines what can be expected on a specific day of hospitalization It is reviewed with the patient each day, it lists: Diagnostic and Laboratory tests such as ( e.g. Xrays, MRI, PFT, CBC, BMP, PTT,PT, etc...) Medications: Digoxin-dosage time of day 9:00 am and how many times a day, Lopressor and dosage time 9:00 am , and how many times a day Nutrition: such as the type of diet that pt is on such as- (Diabetic 1800 cal diet/ hs snack), Regular, 2 Gm sodium, and even if their is a 1200, 1500 or 1800 cc fluid restriction. It lists appointments @ the facility if their is a follow up appointment after discharge that day or while they have a stay there. It also lists their Allergies to medicines if any, it also lists their goals like No Falls, decreased shortness of breath,Decreased Anxiety, It also lists any Physical Therapy , Breathing Treatments ,Occupational Therapy the Dr has ordered for the patient,this is what a daily plan of care entails, I hope this helps you out!!!

Ok that helps! I just needed some content and direction. Thank you both!

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