Nursing Care Plan

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 order 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 order 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 order 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