Nursing care plan

Pathophysiology of Medical History (3)

Surgical History

Social History

Patient Info (1)

Name:

Age:

Gender:

Code Status:

DPOA:

Living Will:

Allergies:

Erickson’s Developmental Stage Related to pt. & Cite References (1)

Chief Complaint

Admitting Diagnosis

Concept Map

Student Name:

Instructor: Blackard

Medical Management/ Orders/ Medications & Allergies (2)

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

Medical Management/ Orders/ Medications & Allergies

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

Medical Management/ Orders/ Medications & Allergies

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

Medical Management/ Orders/ Medications & Allergies

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

Cultural considerations, ethnicity, occupation, religion, family support, insurance.

Diagnostic Test/ Lab Results with dates and Normal Ranges

Test

Norms

Date

Current Value

WBC

4.40-11

Hgb

14.0- 16.0

Hct

36-42

Platelets

150-450

Na+

135-145

K+

3.5-5.0

Creatinine

0.6-1.3

Blood Glucose

76-106

BUN

8.0-30.0

Troponins

0.0-0.4

BNP

>125pg/mL

ALT

7 to 56

Ca+

8.5 – 10.5

Albumin

3.5 – 5.5

AST

10- 40

Blood cultures

Cholesterol

100 to 129

Triglycerides

HDL

40 - 59

LDL

100 -129

Neurological

Vital Signs (4)

Cardiovascular

Respiratory

Rest/Exercise

Nutrition/Hydration

Misc. (Ht/Wt)

Integumentary

GI

GU

Psychosocial (14)

Endocrine

Patient Education (In Pt.) & Discharge Planning (home needs )

Patient Education while in patient:

Discharge Planning/Education:

Priority nursing diagnosis #1

Priority nursing diagnosis #1

Outcome/Goal #1

Outcome/Goal #2

Interventions #1

Assessment/ Evaluation #1

Interventions # 2

Assessment/ Evaluation #2

PC Outcomes/Goal

.

PC Interventions

Potential Complications/ at risk for

PC Evaluation Plan

References: