Sample Care Plan Template Page 31
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51Diagnostic Testing Worksheet
(e.g. x-ray, ECG, colonoscopy, etc.)
Tests
Purpose of Test
Date of
Test Results
Test
Belly pain, vomiting, stone protocol
2/12
CT Abdomen: The scan showed that there was fatty
infiltration of the liver as well as a right-sided
diaphragmatic hernia containing liver. The patient
CT abdomen pelvis w/o IV
had extensive evidence of atherosclerotic disease and
contrast
a left lower pulmonary nodularity.
CT Pelvis: There was no obvious free pelvic fluid and
bladder was unremarkable.
rd
Duotube placement
2/17
The tip of the duotube is in the 3
segment of the
X-ray abdomen
duodenum.
Follow up due to aspiration of vomiting
2/17; 2/18;
Lungs show improvement in each follow up x-ray.
X-ray chest
2/19
The right lower lobe airspace opacities are starting to
resolve.
X-ray chest
Line placement of right subclavian CVC
2/15
Line in appropriate place and cleared for use.
X-ray chest
Confirmation of Endotracheal tube placement
2/15
ETT placed correctly.
The patient’s left ventricular systolic function is
Concern of alcoholic cardiomyopathy
2/17
normal with an ejection fraction of 55-65 %. There is
Echocardiogram
evidence of mild concentric and a diastolic filling
pattern that indicates impaired relaxation (Grade 1).
Page 31
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
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