PLAN OF CARE:
(critical ill, stable, guarded)
b. Nursing orders:
(you’ve all been nurses…so write exactly what the nurses will need to know/do/etc.
Drug: dose, route, time, and side effect/ teaching, monitoring must be included
c. Referrals with rationale:
(many patients will need referrals to specialists. However, remember it can take 24 hours at LEAST for them to show up). Always manage the patient appropriately until it is reasonable that specialist will show up.
d. LABS requested and rationale:
(these are not repeat labs from your initial assessment/diagnosis..but follow labs)
e. Test requested and rationale:
(Are there critical tests they will need overnight/the next day?)
f. Supportive services:
There is more to being an NP than prescribing. Look at the supportive services required, PT/ OT, Dietary, REHAB, etc and make referral. If in your opinion there is none, then state that.
g. Patient education:
(include family if minors on disease, management and or drugs)
h. Follow up or disposition:
Discharge planning. When coming back and why?
i. Ancillary orders:
Pain management, sleeper, bowel program, PPI protection, DVT protection etc.
j. Health Maintenance and Prevention:Age appropriate
k. Reference list: Minimum 7 to support your treatment plan