Nursing Care Plan
Care Plan
Course Number and Name
Course: NURS 210L-AB
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
| 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) supported with Evidence Based Citations |
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations |
|
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations |
Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations |
|
Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations |
Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations |
|
Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx) |
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations |
Signs and
Symptoms
As evidenced by
Related to
Contributing
Factors
Diagnostic
Label
|
Priority Nursing Diagnosis (at least 2) Written in three part statement |
Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) |
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) |
Rationale Each must be supported with Evidence Based Citations |
Evaluation Goal Met, Partially Met, or Not Met & Explanation |
MEDICATION LIST
| Medications (with APA citations | Class/Purpose | Route | Frequency |
Dose (& range) If out of range, why? |
Mechanism of action Onset of action |
Common side effects |
Nursing considerations specific to this patient |
Revision Date: Month, Year (i.e. February, 2010) Page 1
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