Stroke Care Plan

In: Other Topics

Submitted By Shopkins411
Words 3603
Pages 15
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Clinical Preparation Worksheet- Information Necessary for Care
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Your Name _ Date of Care_3/17/2014_____ Pt. Initials__M.A.____________
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Pt. age__51_______ Code Status _Full Code______________Braden /SKIN Score __K_____
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Fall Risk- Fall risk with high injury probability __Level 2________________
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Admitted from: Home/extended care facility? __Home___________________
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Reason for admission - also called CC or Chief complaint: (This is in the pt.’s words. Ask them why they came to the hospital and record what they say as a direct quote.)
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Fell in the shower and became unconscious, tried to call girlfriend but couldn’t move left side
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Admitting Medical Diagnosis/Diagnoses:
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Stroke
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Medical and Surgery History: Note if problem remains active (A) or resolved (R)
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Stented coronary artery (A)
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Partial occlusion of retinal vein (A)
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Left meniscal tears X2 arthroscopic (A)
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Hyperlipidemia (A)…...

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