Sample Care Plan Template Page 12
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51Use of O
(e.g. nasal cannula, mask, trach collar, other):
2
The patient is on a ventilator.
Oxygen sat: 100%
Humidification: On per vent settings
Type of airway: Endotracheal tube with a 7.5 cm
diameter
cm mark: 25 cm
Vent settings: TV: 400 Rate: 14 Mode: PRVC FIO2: 40 PEEP: 5
PS: None
Cardiovascular system
Pulses (e.g. strong, weak, bilateral, with locations):
The patient’s pulses upon assessment were strong 2+ bilaterally on both upper and lower
extremities.
Capillary Refill (in seconds):
Less than 2 seconds
Jugular Vein Distention (JVD):
No obvious signs of JVD.
Edema (e.g. location, degree, pitting):
The patient has slight edema in his hand and left foot (1+) with no pitting.
Extremity temperatures:
The patient’s extremities are normothermic.
Sounds (e.g. S
, S
, regular/irregular, murmur):
1
2
Upon auscultation the patient’s has both S1 and S2 sounds with no murmur and a regular
rhythm.
Chest pain (e.g. PQRST):
None.
Other (Pacemaker, AICD, etc.):
None.
Telemetry (describe cardiac rhythm):
The patient has a normal sinus rhythm with both PAC’s and PVC’s present.
Other monitor devices (swan, a-line, CVP, IABP)
The patient’s blood pressure is monitored directly through his A-line.
Skin and Wounds
Assess patient’s skin, wounds, pressure ulcer (stage), dressings, and drains.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan/12/17/2012
Page 12
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