Nursing Care Plan Student Course Date Instructor Patient IN DOB Age DOA Ht Wt Unit Room# Allergies Admission Diagnosis (2pts) Diagnostic Procedures/Surgeries (include (2pts) Discharge Referrals (2pts) Include dates Date not please state so Erickson’s Developmental Stage with Socioeconomic/Cultural Orientation (2pts) Psychosocial Considerations (2pts) Rationale (2pts) (APA citation) History of Present Illness Past Medical History Pertinent lab test (normal ranges in (presenting signs & symptoms/diagnostic Past Surgical History (Concurrent, onset, dates) (2pts) parentheses) & diagnostic reports reports) (2pts) Date not please state so (with dates) (2pts) Rationale for Abnormal Labs Pathophysiology of admitting and/or Collaborative Problems Rationale for Orders related medical diagnosis Current Prescriber’s Order (with APA citations) (2pts) Describe How this diagnosis relates to your (include diet, test, and treatments) (2pts) patient (with APA citations) (5pts) Identify Potential Health Deviations Related Factors Interventions (at least two each) (“At Risk for…” nursing dx) (5pts) (of risk” condition, signs and symptoms (Independent Nursing Functions) (10pts) “at should they manifest) (5pts)
Nursing Care Plan Student Course Date Instructor Patient IN DOB Age DOA Ht Wt Unit Room# Allergies Admission Diagnosis (2pts) Diagnostic Procedures/Surgeries (include (2pts) Include dates Date not please state so Discharge Referrals (2pts) Erickson’s Developmental Stage with Rationale (2pts) (APA citation) Socioeconomic/Cultural Orientation (2pts) Psychosocial Considerations (2pts) History of Present Illness (presenting signs & symptoms/diagnostic reports) (2pts) Past Medical History Past Surgical History (Concurrent, onset, dates) (2pts) Date not please state so Pertinent lab test (normal ranges in parentheses) & diagnostic reports (with dates) (2pts) Rationale for Abnormal Labs Pathophysiology of admitting and/or related medical diagnosis Describe How this diagnosis relates to your patient (with APA citations) (5pts) Collaborative Problems Current Prescriber’s Order (include diet, test, and treatments) (2pts) Rationale for Orders (with APA citations) (2pts) Identify Potential Health Deviations (“At Risk for…” nursing dx) (5pts) Related Factors (of “at risk” condition, signs and symptoms should they manifest) (5pts) Interventions (at least two each) (Independent Nursing Functions) (10pts)
NURS+216L+02.2011-LatestV.docx