NURSING CARE PLAN
Student Name:
Date Submitted: _____________________
Patient Initials:
Age/Sex
Medical Diagnosis
Complete using your nursing textbooks (cite references used). Underline the etiologies and clinical manifestations that relate to your client.
I.
Pathophysiology:
II.
Etiology:
III.
Clinical Manifestations (Signs & Symptoms):
IV.
Treatment and Nursing Management:
V.
Diagnostic Studies/Lab Analysis
Test
Date
Client’s Result
Normal Result
Reason
VI.
Discharge Planning and Client Teaching
VIII.
Growth & Development
According to Erikson: Stage: _______________
Crisis: ________________________
Tasks:
A.
Describe your patient’s ability to achieve their growth and developmental tasks. How is this ability affected by the underlying disease process and/or the current admission?
B.
List nursing actions to assist your client in meeting their growth and developmental needs.
IX.
List in priority
all
relevant nursing diagnoses for your patient. Include NANDA diagnosis, etiology and supporting data.
Assessment Data
Identify all data that support the priority nursing diagnosis.
Nursing Diagnosis
According to NANDA
Nursing Actions
List in of priority.
Rationale
State the rationale for each nursing action. Cite reference and page number.
Evaluation
Evaluate the patient response to each nursing action providing objective & subjective data. Revise nursing actions as necessary.
Expected Outcome:
Short Term Goal (STG):
Long Term Goal (LTG):
Evaluate each expected outcome:
Short Term Goal (STG):
Long Term Goal (LTG):
Assessment Data
Identify all data that support the priority nursing diagnosis.
Nursing Diagnosis
According to NANDA
Nursing Actions
List in of priority. Label aspect of care.
Rationale
State the rationale for each nursing action. Cite reference and page number.
Evaluation
Evaluate the patient response to each nursing action providing objective & subjective data. Revise nursing actions as necessary.
Expected Outcome:
Short Term Goal (STG):
Long Term Goal (LTG):
Evaluate each expected outcome:
Short Term Goal (STG):
Long Term Goal (LTG):
MEDICATION PREPARATION SHEET
Allergies:
Med as per MAR:
MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:
Major Side Effects:
Parameters Checked:
Med as per MAR:
MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:
Major Side Effects:
Parameters Checked:
Med as per MAR:
MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:
Major Side Effects:
Parameters Checked:
Med as per MAR:
MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:
Major Side Effects:
Parameters Checked:
Write the care plan regarding this patient: Acute Pain due to surgey
Male guy , age 70 years, left side hip surgery,
Vitals are:
Bp 131/73
Pulse 68
HR 64
Temp 36.8
Respiratory rate 16
Capillary refill less than 3
PERLA
Warm moist skin
Lab values
Hamoglobin 9.7 Normal should be 12.6-17.4
Hematocrite 27.1 noraml should be 37.0-50%
BUN 34 Normal should be 9-20
Creatine 1.28 0.66-1.25
Medication:
Magnesium Oxide 400mg
Metoprolol 25mg
Aspirin 81mg
Norvase 10mg daily
Pt is on high risk fall
Pt doesnot take fluid
Urine incontinence
Constipation
Immobile
NURS 142 Care Plan Form Fall 2019
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