Nursing care plan
CARE PLAN
Student Name: __________________________________ Date: _________________
Patient initials: _______ DOB__________
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Assessment |
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Subjective Data |
Objective Data |
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Patient stated problems |
Identified problems |
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Patient Problem and Nursing Diagnosis |
Interventions and Rationale |
Goals and Evaluation |
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Patient Problem #1:
Nursing Diagnosis #1:
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1.
Rationale:
2.
Rationale:
3.
Rationale:
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Short term goal:
Long term goal:
Evaluation:
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Patient Problem and Nursing Diagnosis |
Interventions and Rationale |
Goals and Evaluation |
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Patient Problem #2:
Nursing Diagnosis #2:
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1.
Rationale:
2.
Rationale:
3.
Rationale:
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Short term goal:
Long term goal:
Evaluation:
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Medications |
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Drug Name (generic and trade name) and classification |
Dose, Route, Frequency |
Medication Indication |
Indications for patient use |
Adverse Side effects |
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Nursing responsibilities:
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