NURSING CARE PLAN PSYCHIATRIC

Client Initials:

Culture/Ethnicity:

Support system:

Unit: Room/Bed:

Religion:

Age: Sex: female

Language:

Weight: Height: BMI:

Marital status:

Current medical diagnosis

Occupation:

Siblings:

Health insurance:

Name of significant other/primary caregiver

Current work status:

Highest grade completed:

Genogram:

Diagnostic procedures:

Surgical procedures:

DEVELOPMENTAL STAGE/THEORIST

Vital signs:

Allergies/Side effects:

Diet with rationale:

Activity:

Limitations/prosthetic devices:

BRIEF HEALTH HISTORY

PERTINENT LABORATORY DATA Lab Test #1

_______________________

Results:

.

PERTINENT LABORATORY DATA Lab Test #2

______________________

Results:

PERTINENT LABORATORY DATA Lab Test #3

______________________

Results:

PERTINENT LABORATORY DATA Lab Test #4

_______________________

Results:

MEDICATION NAME

TRADE/GENERIC

DOSE ORDER

TIMES ADMINISTER

ROUTE

RATIONALE

RANGE

NURSING IMPLICATIONS

.

NURSING DIAGNOSES

DESCRIBE RATIONALE FOR PRIORITY ORDER

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

.