care plan

careplan2.docx

NEW PROFESSIONS TECHNICAL INSTITUTE

4000 West Flagler Street Miami, Florida 33134

(305) 461-2223 / Fax: (305) 461-3029

STUDENT NAME: DATE:

CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES: Advance Directives: Restrains: Y / N DIET (including tube feeding with rate)

Admitting Medical Diagnosis:

Chief Complaint:

History of Present illness:

Past Medical History:

Cultural and Spiritual Assessment:

Medications taken at home or before transfer: (include dose and frequency)

Summarize Pathophysiology (in our own words, include definition, etiology and physiology)
Definition of Concurrent Diagnoses (all of them)	Correlational of all diagnoses with current condition


Signs and Symptoms: (Indicate which ones your client has)	Diagnostic test for this condition: (Indicate which ones utilized for client)
Treatment (med/surg/pharmacological)	Nursing Interventions and rationale:

Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.

Generic/Trade Name Classification

Major Action

Reason Prescribed to Client

Dose Given/Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication

Generic/Trade Name Classification	Major Action Reason Prescribed to Client	Dose Given/ Normal Range	Adverse Effects Precautions/Contraindications	Nursing Implication

Generic/Trade Name Classification	Major Action Reason Prescribed to Client	Dose Given/ Normal Range	Adverse Effects Precautions/Contraindications	Nursing Implication

LABORATORY AND DIAGNOSTIC TESTS

Other Pertinent labs

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS	SCIENTIFIC PRINCIPLE/ RATIONALE	EVALUATION	MODIFICATION

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS	SCIENTIFIC PRINCIPLE/ RATIONALE	EVALUATION	MODIFICATION

DISCHARGE PLANNING