Mini Care a 68 year old man came to the hospital due to vomiting, he was put inthe  obseversation  room for 48 hours, HE went to a CT scan to rule out TIA,

Mini Care a 68 year old man came to the hospital due to vomiting, he was put inthe  obseversation  room for 48 hours, HE went to a CT scan to rule out TIA,

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Mini Care a 68 year old man came to the hospital due to vomiting, he was put inthe  obseversation  room for 48 hours, HE went to a CT scan to rule out TIA, he also went for an MRI , all result were okay.. he was discharge home since he was perfectly fine. . all his lab value were okay

History: he is diabetic, has a history of HTN….  he was friendly, alter and oriented times 4.

fill out the mini care for this client.

please fill in all the mising information School of Health Professions, Science and Wellness

Department of Nursing

Clinical log (Mini Care Plan)

Client Code Name: _____________________________

Client’s Age: _________ Gender: ________________

Present Medical Diagnoses: ____________________________________________________________________________

Present Surgery (if applicable): _____________________
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
____________________________________________________________________________________________________

Spiritual Well-Being: __________________________________________________________________________________
Allergies: __________________________ Code Status: _________________________

Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________
General Appearance:
Psychiatric:
HEENT:
Neck and Lymph Nodes:
Pulmonary:
Cardiovascular:
Skin and Nails:
Abdomen:
Genitourinary:
Pelvic and Rectal:
Extremities:
Musculoskeletal:
Neurological (DTR’s, reflex grading, cranial nerve evaluation):
Incisions:
Drains:
Diet/Nutrition:
IVs: Intake and Output:

Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):
Pain assessment (include reassessment):

Time

Score

Intervention

Reassessment Time

Score

Diagnostic Assessments – Important EKGs, X-Rays, and Labs

Lab/Other Test

Patient values

Inference

Medications Ordered for Client:

Medication and
Dose with Brand name

Generic Name of Drug

Times of Administration

Indications of Drug

Adverse Effects

Nursing Implications

Treatments and Procedures

Day & Times

Rationale

Nursing Interventions:

Assessment Findings

Nursing Diagnoses

Expected Outcomes

Nursing Interventions

Evaluation

Reflections of the day:

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