COMPLETE THE CARE PLAN USE THE ADJ TEMPLATE.
CAN USE ANY PEDIATRIC CASE.
Page 1 of 10
Nursing Care Plan
NURSING (AS) Program
Student Name: ____________________________________
Date: ____ / ____/ ______
Initial:
Sex: M / F
Date of Admission: /
/
Admitting Diagnoses:
1)
2)
3)
4)
5)
Patient Past Medical History:
Instructor: __________________________
Clinical Site: _______________________________
Patient Information
Age:
Ethnic Group:
Allergy:
Weight:
Past Surgical History:
Social History:
History of Present Illness: (If additional Space is needed please continue on the back of this page)
NURSING CARE PLAN
White / AA / Hispanic / Asian
Diet:
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Subjective Findings
(If additional space is needed please continue on the back of this page)
Vital Sign: BP:
HR:
RR:
Objective Finding
Temp:
Physical Assessment Findings:
Laboratory Studies:
CBC
NURSING CARE PLAN
Metabolic Panel
Coagulation
Other: (U/A, ABG’s, Protombin, etc.)
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Imaging Result: (X-Ray, CT Scan, MRI, MRCP, Ultrasound…….)
Endoscopic Result: (colonoscopy, EGD…..)
What is the relation between these diagnostic tests with the patients disease and or present illness?
NURSING CARE PLAN
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Analysis:
What are the potential complications / problems for this patient?
NURSING CARE PLAN
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Medication List
Medication/Order
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Usage
Usual Dose
Side effects
Nursing Intervention
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Nursing Care Plan
Once evaluated patient’s past and present history: select at least three nursing diagnoses from highest to lowest priority. Give nursing interventions
(dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses.
Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
NURSING CARE PLAN
Desired Outcome
Nursing Interventions / Rationales
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Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
NURSING CARE PLAN
Desired Outcome
Nursing Interventions / Rationales
Page 8 of 10
Nursing Diagnoses
(…..related to…..secondary to ….evidenced
by…..)
NURSING CARE PLAN
Desired Outcome
Nursing Interventions / Rationales
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Patient’s Care Plan Evaluation of Outcomes:
NURSING CARE PLAN
Page 10 of 10
Student Evaluation
(To be completed by faculty only)
Comments:
Student Needs to Improve on:
FINAL GRADE: _____________________
Instructor’s Signature: _____________________________
Date of evaluation: _________________
Student’s Signature: _______________________________
NURSING CARE PLAN
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Formatting
Title Page
Citation
Outline
