Care plan and Concept Map for Medical-Surgical (Nursing)
Pearl_shun
N210MajorCarePlan.docx
City Colleges of Chicago
School of Nursing
Nursing 210
Intermediate Medical-Surgical Nursing
Major Clinical Plan of Care
Student Name: Date:
Patient’s initials:
Race:
Age:
Birth Gender:
Preferred Gender:
Source of Information:
Marital Status:
Primary Medical Diagnosis:
Secondary Medical Diagnosis:
Vital signs:
T:
P:
R:
B/P:
SP02:
Pain Score (1-10):
Location:
Allergies:
Diet:
Chief Complaint (CC) or Reason for Seeking Emergency Care
History of Present Illness or Problem (HPI) (Subjective data from pt, patients own words):
Past Medical History (PMH)
Review of Systems (ROS) (Subjective data from pt, patients own words)
General (weight +/-, fever, chills, fatigue, etc):
Skin:
Musculoskeletal:
Head and Neck:
Endocrine (Diabetes, thyroid review):
Females (Menses, Pregnancies, Breast, etc.): -
Males (Prostate):
Chest and Lungs:
Heart and blood vessels:
Hematologic:
Lymph Nodes:
Gastrointestinal:
Genitourinary:
Neurological:
Psychiatric/Mental Health:
Physical Exam (Objective data from YOUR exam)
General:
Neurological:
Head Eyes Ears Nose Throat (HEENT):
Head/neck:
Eyes:
Ears:
Neck:
Lymph nodes:
Axillary:
Groin:
Cardiovascular:
Heart Sounds:
Cap Refill:
Pulses:
Chest and Lungs:
Chest/breast:
Lungs:
Abdomen/gastrointestinal:
Genitourinary:
Rectal:
Musculoskeletal:
ROM:
Edema:
Strength/sensation:
Skin:
Temp:
Color:
Condition:
Psychiatric/Mental Health:
Suicidal/homicidal:
Mood/Affect (ex: flat, agitated, tearful, anxious, etc.):
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Significant (labs r/t your primary diagnosis) AND/OR abnormal Labs (r/t pt condition): |
Interpretation (what does that mean for your pt and care):
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Procedures, Surgeries or Treatments |
Interpretations/Results: |
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IVF’s
1) Primary IV solution ordered:
Rate ml/hr
Rationale for solution:
2) Primary IV solution ordered:
Rate ml/hr
Rationale for solutions:
3) Secondary IV solution ordered:
Rate ml/hr
Rationale for solutions:
IV drip ordered:
Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.
Rationale for solution:
IV drip ordered:
Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.
Rationale for solution:
Rev 09/2022
Medications Administered During Clinical
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Classification: (ex: beta blocker, GLP-1, etc.)
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Dosage/Route/Frequency:
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Side Effects:
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Nursing Responsibilities: (ex: administration, VS, pt teaching, etc.)
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(NANDA) Physical (1)
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Planning/Outcome Goal (SMART goals)
Short Term (Shift):
Long Term (>48 hours):
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Nursing Actions (Interventions)
1.
2.
3.
4.
5.
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Rationales:
1.
2.
3.
4.
5. |
Evaluation: Was the goal met, in progress or unmet?
Explain?
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Nursing Diagnosis: (NANDA) Physical (2)
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Planning/Outcome Goal (SMART goals)
Short Term (Shift):
Long Term (>48 hours):
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Nursing Actions (Interventions)
1.
2.
3.
4.
5.
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Rationales:
1.
2.
3.
4.
5. |
Evaluation: Was the goal met, in progress or unmet?
Explain?
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Nursing Diagnosis: (NANDA) Psychosocial (1)
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Planning/Outcome Goal (SMART goals)
Short Term (Shift):
Long Term (>48 hours):
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Nursing Actions (Interventions)
1.
2.
3.
4.
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Rationales:
1.
2.
3.
4. |
Evaluation: Was the goal met, in-progress or unmet?
Explain?
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Primary Medical Diagnosis
Pathophysiology of disorder:
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Shift Report Nursing Note (SBAR) |
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S:
B:
A:
R:
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References
(Must be in APA format, must include 2 current nursing references outside of textbook. References must be published within the past 5 years)
RESEARCH ARTICLE (Please Attach)
Author(s)- must be written by at least one nurse:
Year (no later than the last 5 years):
Journal Name:
Volume, Issue, and Pages:
Title:
Summary of article in your own words, and how to best incorporate in your plan of care.
______ _____________________________________________________________________________________________________
