Care Plan

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Student: Date:

Patients Initials: Age: Sex: Race/Ethnicity: Admit Date: Code Status:

Height (cm): Weight (date & Kg): BMI:

Diet: ADLs:

Brief Social History (Tobacco, ETOH, drug use; family dynamics; support system):

Religion/Spiritualism:

Culture:

Occupation/Hobbies/Interests:

Living Situation (Re: safety, available assistance, emotional/social support, physical requirements)

Admit Medical Dx (Primary): Secondary:

Definition from Taber’s for Primary Admitting Medical Dx (cited and referenced):

Etiology/pathophysiology for Primary Admitting Medical Dx - NOT from Taber’s - (cited and referenced):

Common S/S (cited and referenced):

Common complications (cited and referenced):

Primary C/O: Why did patient get admitted? (Patients words):

Procedures/Surgeries this admission:

Past Relevant Patient Medical Hx (Related to this admission or potentially impacting patient progress, care, or discharge planning for this admission)

Relevant Family Medical Hx (Genetic/environmental risk factors for patient - specify parent, sibling, grandparent):

Diagnostic Testing (X-ray, MRI, CT, etc.):

Allergies:

IV Site: Size: Date: IV Fluids/rate: IV site assess:

Medications (include pertinent PRN meds):

Medication/Class

Dose/Route/Frequency

Action/Purpose

for Patient

Side Effects/ Contraindication

Nursing Implications

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindications:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindications:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Drug:

Class:

Dose:

Route:

Frequency:

Action:

Purpose for Pt:

Side Effects:

Contraindication:

Assessment & Drug Effects:

Patient & Family Education:

Lab Data (List Basic Chemistry, CBC, pertinent labs, abnormal labs)

Lab Test

Date

Description of Test

Normal Value

Patient Results

Reason for Abnormal (for this patient)

CBC – Complete Blood Count

WBC

RBC

Hgb

Hct

Plt

Chemistry

Na

K

Glucose

Mg

BUN

Creatinine

GFR

Additional Labs

Head to Toe Physical Assessment

Integument:

Neuro:

Cardiovascular:

Respiratory:

Tele:

O2:

GI:

GU:

Last BM:

Psych:

M/S:

Special:

What I did for my patient:

What I learned from/about my patient:

What I would do differently:

Blood Glucose Accu Checks

Time

Result

Insulin Coverage Given (type, amount)

List any medical equipment/devices in or on body w/type or

location (oxygen or gastric tubes, urinary catheters, SCDs,

casts/braces/binders, nonremovable bandages…):

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Vital Signs and Pulse Oxygen (Indicate context as well as time if this may have impact -

such as walking vs at rest, before or after an intervention, etc… Record site for each.

Give rate, rhythm and quality/depth for pulse/respiration. Describe intensity,

frequency, duration and quality for pain; indicate what makes pain better & worse)

Time/context

Temp

Pulse

Resp

BP

O2Sat

Pain Level

Nursing Plan of Care (please refer to rubric when completing this form)

Objective Cluster Data (for this problem)

Subjective Cluster Data (for this problem)

Priority Nursing Diagnosis 1: (Must be Actual Diagnosis and must be Physical Need on Maslow’s hierarchy)

Goals (List one short term goal)

STG:

STG Interventions (List 3, with rationales & citation)

1.

2.

3.

Goals (List one long term goal)

LTG:

LTG Interventions (List 3, with rationales & citation)

1.

2.

3.

EVALUATION: (State if when goals were evaluated, if goals were met/not met and why; If goal should continue/discontinue or be revised)

Priority Nursing Diagnosis #2 (Must be Actual Diagnosis; may be any need on Maslow’s Hierarchy - specify which need - as long as it is a priority):

Goals (List one short term goal)

STG:

STG Interventions (List 3, with rationales & citation)

1.

2.

3.

Goals (List one long term goal)

LTG:

LTG Interventions (List 3, with rationales & citation)

1.

2.

3.

EVALUATION: (State if when goals were evaluated, if goals were met/not met and why; If goal should continue/discontinue or be revised)

Priority Nursing Diagnosis #3 (Must be Risk for Diagnosis; must specify which need on Maslow’s Hierarchy; must be Safety Need if diagnosis #2 is not):

Goals (List one short term goal)

STG:

STG Interventions (List 3, with rationales & citation)

1.

2.

3.

Goals (List one long term goal)

LTG:

LTG Interventions (List 3, with rationales & citation)

1.

2.

3.

EVALUATION: (State when goals were evaluated, if goals were met/not met and why; If goal should continue/discontinue or be revised)

References

Keiser University School of Nursing

Fundamentals Care Plan

5

References

Keiser University School of Nursing

Clinical Form

5

References

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