Patient’s Initials ________________ Patient’s Age ...
NURSING CARE PLAN
Patient’s Initials ________ Room ______ Age _____ Sex _____Religion _______ Occupation _____________________________
Diet _____________ Allergies___________________________ Primary Diagnosis ______________________________________
Medical History _____________________________________________________________________________________________
Surgical History _____________________________________________________________________________________________
Social History _______________________________________________________________________________________________
Current Medications (Include route, dosage, frequency & pharm. classification) ________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Current Treatments__________________________________________________________________________________________ ___________________________________________________________________________________________________________
Diagnostic Tests (List most current test, patient results, and reason for test) _______________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________Laboratory tests (List the most current 3, normals and patient results, and significance in this patient for abnormal results) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT SYSTEM ASSESSMENT
Vital Signs: T____ P ____ R ____ BP ____ HT ____ WT____
Neurological ________________________________________________________________________________________________
____________________________________________________________________________________________________________
Cardiovascular ______________________________________________________________________________________________
____________________________________________________________________________________________________________
Respiratory _________________________________________________________________________________________________
____________________________________________________________________________________________________________
Gastrointestinal _____________________________________________________________________________________________
____________________________________________________________________________________________________________
Genitourinary _______________________________________________________________________________________________
____________________________________________________________________________________________________________
Integumentary ______________________________________________________________________________________________
____________________________________________________________________________________________________________
Musculoskeletal _____________________________________________________________________________________________
____________________________________________________________________________________________________________
|NURSING DIAGNOSIS #1 |GOAL |INTERVENTIONS (5 OR MORE) |RATIONALE FOR INTERVENTION |EVALUATION |
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|NURSING DIAGNOSIS #2 |GOAL |INTERVENTIONS (5 OR MORE) |RATIONALE FOR INTERVENTION |EVALUATION |
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|NURSING DIAGNOSIS #3 |GOAL |INTERVENTIONS (5 OR MORE) |RATIONALE FOR INTERVENTION |EVALUATION |
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NURSING CARE PLAN
GRADING CRITERIA
ALL SECTIONS MUST BE NEAT, LEGIBLE, AND COMPLETE AND ALL TERMS SPELLED CORRECTLY.
2 pts Identifying information to “Primary diagnosis”
3 pts each Medical history/Surgical history/ Social history
(Must include pertinent medical history, surgery dates, substance use, and any other significant information)
5 pts each Medications/Treatments/Diagnostic Test/Laboratory Tests
Must include all information as directed on plan.
9 pts Patient System Assessment
Objective findings must be included. Normal and/or abnormal findings for each system. (Ex.: PV – Pedal pulses palpable. No edema. Both feet warm with equal color.)
Also include subjective findings when appropriate. (Ex: pain, nausea, loss of appetite, etc.)
“NORMAL” or ”NOT APPLICABLE “ IS NOT ACCEPTABLE. Keep it brief and concise, but complete.
6 pts each Nursing Diagnoses (Problem)
Must be appropriate and stated using P-E-S format.
Must choose problems based on Maslow’s Hierarchy. Minimum of 2 different level problems, first problem must be physiological.
6 pts each Goals
Must be stated correctly, measurable, and include time frame, and must be related to the stated nursing diagnosis.
5 pts each Interventions/Rationale
Must be specific nursing actions, stated clearly, and related to diagnosis and goal. Rationales (reason) must be given for each action.
3 pts each Evaluation
How would you evaluate whether your goals had been achieved?
Total 100 pts possible (Point values per section evaluated. There are no partial points given)
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