Course Number and Name
Course: NURS 210L-AB
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
| Student | 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
Page 3 of 3
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
Read moreYour email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
Read moreBy sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
Read more