NPTI Signs of Arrhythmia Care Plan

NEW PROFESSIONS TECHNICAL INSTITUTE4000 West Flagler Street Miami, Florida 33134
(305) 461-2223 / Fax: (305) 461-3029
STUDENT NAME: DATE:
CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES: Advance Directives:
Restrains: Y / N DIET (including tube feeding with rate)
Admitting Medical Diagnosis:
Chief Complaint:
History of Present illness:
Past Medical History:
Cultural and Spiritual Assessment:
Medications taken at home or before transfer: (include dose and frequency)
Summarize Pathophysiology (in our own words, include definition, etiology and physiology)
Definition of Concurrent Diagnoses (all of them)
Correlational of all diagnoses with current condition
Signs and Symptoms: (Indicate which ones your client has)
Diagnostic test for this condition: (Indicate which ones
utilized for client)
Treatment (med/surg/pharmacological)
Nursing Interventions and rationale:
Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.
Generic/Trade
Name Classification
Major Action
Reason Prescribed
to Client
Dose
Given/Normal
Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
.
Generic/Trade
Name Classification
Major Action
Reason Prescribed
to Client
Dose Given/
Normal Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
Generic/Trade
Name Classification
Major Action
Reason Prescribed
to Client
Dose Given/
Normal Range
Adverse Effects
Precautions/Contraindications
Nursing Implication
LABORATORY AND DIAGNOSTIC TESTS
Other Pertinent labs
DATE
DIAGNOSTIC STUDY
RESULTS
SIGNIFICANCE TO PATIENT
NURSING DIAGNOSIS R/T AND EVIDENCED BY
Subjective Supportive Data
Objective Supportive Data
NURSING ACTIONS
SCIENTIFIC
PRINCIPLE/
RATIONALE
EVALUATION
MODIFICATION
NURSING DIAGNOSIS R/T AND EVIDENCED BY
Subjective Supportive Data
Objective Supportive Data
NURSING ACTIONS
SCIENTIFIC PRINCIPLE/
RATIONALE
EVALUATION
MODIFICATION
DISCHARGE PLANNING
CLIENT’S NEED FOR DISCHARGE
INTERVENTIONS
RATIONALE