Nursing Care Plan Student Course Date Instructor Patient Initial _____________ Age _______________ Height/Weight Unit Room# Code Status_____________ Allergies_____________________________________________________________________________________ Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain 1-10 History of Present Illness including Admission Diagnosis Relevant Diagnostic Procedures/Results & Surgeries Relevant Physical Assessment Findings(normal & abnormal) (include dates, if not found state so) (with normal ranges), Past Medical & Surgical History, Pertinent Lab tests/ Values Pathophysiology of medical diagnoses with dates and rationales (with APA citations) Erikson’s Developmental with Rationale Socioeconomic/Cultural/Spiritual Orientation (APA citation) & Psychosocial Considerations Potential Health Deviations, Predisposing &Related Factors; Interprofessional Consults, Discharge Referrals, & Current Interventions to assess or prevent potential health deviations Orders(include diet, test, and treatments) with Rationale (“At Risk for…” nursing dx) (AT TWO) (with APA citations)
Nursing Care Plan Student Course Date Instructor Patient Initial _____________ Age _______________ Height/Weight Unit Room# Code Status_____________ Allergies_____________________________________________________________________________________ Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain 1-10 History of Present Illness including Admission Diagnosis Relevant Physical Assessment Findings(normal & abnormal) Relevant Diagnostic Procedures/Results & Surgeries (include dates, if not found state so) Past Medical & Surgical History, Pathophysiology of medical diagnoses (with APA citations) Pertinent Lab tests/ Values (with normal ranges), with dates and rationales Erikson’s Developmental with Rationale (APA citation) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations Potential Health Deviations, Predisposing &Related Factors; Interventions to assess or prevent potential health deviations (“At Risk for…” nursing dx) (AT TWO) Interprofessional Consults, Discharge Referrals, & Current Orders(include diet, test, and treatments) with Rationale (with APA citations)
NURS+216L+4-2011-2.docx