Nursing Care Plan Template Discussion Topic

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Student Last name, First name Date Date submitted
Instructor Graham Course 101L-section#
Patient Initial FL Unit/ Room# Leave blank DOB Age in years
Code Status Per scenario Height/Weight Per scenario (metric)
Allergies Per scenario

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10

Self-explanatory

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
Chief Complaint (if possible, use patients words):
Per scenario

HPI (Findings per scenario – organized by system)
Head and Neck –
Respiratory –
Cardiovascular –
Gastrointestinal –
Urogenital –
Central Nervous System –
Musculoskeletal –
Psychiatric –
Integumentary –
Social –
Endocrine –

Normal:
List all that apply per scenario

 

Abnormal:
List all that apply per scenario

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

Pertinent Labs – Per scenario

First Lab name – Define, Normal Range = ___; Explain Indication/Significance & Cite

Second Lab name – Define, Normal Range = ___; Explain Indication/Significance & Cite

Third Lab name – Define, Normal Range = ___; Explain Indication/Significance & Cite

Relevant Diagnostic Procedures – Per scenario

First Test name – Define, Explain Indication/Significance & Cite
Second Test name – Define, Explain Indication/Significance & Cite
Third Test name – Define, Explain Indication/Significance & Cite
PMH – Per scenario

First Diagnosis name – Define, Explain Pathophysiology & Cite
Second Diagnosis name – Define, Explain Pathophysiology & Cite
Third Diagnosis name – Define, Explain Pathophysiology & Cite

…etc

PSH – Per scenario

First Procedure name – Define, Explain Pathophysiology & Cite
Second Procedure name – Define, Explain Pathophysiology & Cite
Third Procedure name – Define, Explain Pathophysiology & Cite

…etc

 

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

Stage Name indicated per scenario – Describe & Cite

Describe why this patient fits this stage

Socioeconomic

Cultural:

Spiritual:

Three psychosocial concerns, based on above assessments:

1.
2.
3.
No need for evidence based citation

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

AT Risk for: ______________________________________________
AEB ____________________________________________________
________________________________________________________

Identify type
First Consult – define, describe why, and cite
Second Consult – define, describe why, and cite
Third Consult – define, describe why, and cite

…etc

 

 

 

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

NANDA Dx __________
R/T ________________
AEB _______________
Use SMART Goals 1 Met
2 Or Partially Met
3 Or Not Met
4 Include Explanation

NANDA Dx __________
R/T ________________
AEB _______________
Use SMART Goals 1 Met
2 Or Partially Met
3 Or Not Met
4 Include 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
Include generic AND brand name

No need to cite per column…one citation per row will suffice
If all medication information came from one source, cite the table here once