NURSING CARE PLAN Student Date Instructor Course Unit/ Patient Initial DOB Room# Code Status Height/Weight Allergies Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 History of Present Illness including Admission Diagnosis & Physical Assessment Findings including presenting signs and Chief Complaint (normal & abnormal)with APA references symptoms with APA references Relevant Diagnostic Procedures/Results & Pertinent Lab Values Past Medical & Surgical History, (with normal ranges), Pathophysiology of medical diagnoses include dates and rationales with APA references (include dates, if not found state so) with APA references Erikson’s Developmental Stage with Rationale Socioeconomic/Cultural/Spiritual Orientation APA references & Psychosocial Considerations/Concerns (3) with APA references Potential Health Deviations, Predisposing & Related Factors; (At Interprofessional Consults, Discharge Referrals, & Current Orders Include (include diet, test, and treatments) with Rationale least two) Interventions to assess or prevent potential with APA references health deviations Include three independent nursing interventions (“At Risk for…” nursing dx)
NURSING CARE PLAN Student Date Instructor Course Patient Initial Unit/ Room# DOB Code Status Height/Weight Allergies Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal)with APA references Physical Assessment Findings including presenting signs and symptoms with APA references Relevant Diagnostic Procedures/Results & Pertinent Lab Values (with normal ranges), include dates and rationales with APA references Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) with APA references Erikson’s Developmental Stage with Rationale APA references Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) with APA references Potential Health Deviations, Predisposing & Related Factors; (At least two) Include Interventions to assess or prevent potential health deviations Include three independent nursing interventions (“At Risk for…” nursing dx) Interprofessional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale with APA references
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