Help with care plan

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Specializes in School Nurse.

I have to write my first care plan on my client. Tomorrow I have to go to the hospital and get information out of the chart. I am a little confused as to what I should be looking out for on the chart. The main DX is CVA. Client has a history of Bladder ca, CHF, HTN. Her LUE are affected by the CVA and she is an aspiration risk. If anyone can give me any pointers as to what to look for in her chart that will help, I would greatly appreciate it. I have to write about all her systems and the patho/ethio for all her DX and HX.

Sarah

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Specializes in med/surg, telemetry, IV therapy, mgmt.

see this thread: https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html - help preparing for clinical day!

when you actually take care of the patient keep in mind that assessment also includes assessing their adls as well as doing a physical exam.

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your care plan must address safety.

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