Nursing
Fappymide1
Unfill_Careplan_CityCollegesofChicago.docx
School of Nursing
Nursing 210
Intermediate Medical-Surgical Nursing
Major Clinical Plan of Care
Student Name_____________________________ Date____________
Patients initials Race: ____________________________ Age:
DOB: 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):
Past Medical History (PMH)
Review of Systems (ROS)
General:
Skin:
Musculoskeletal:
Head and Neck:
Endocrine:
Females: Menses, Pregnancies, Breast
Males: Prostate:
Chest and Lungs:
Heart and blood vessels:
Hematologic:
Lymph Nodes:
Gastrointestinal:
Genitourinary:
Neurological:
Psychiatric/Mental Health:
Physcial Exam
General:
HEENT:
Neck:
Chest and Lungs:
Cardiovascular
Abdomen/gastrointestinal:
Genitourinary:
Rectal:
Musculoskeletal:
Lymphnodes
Skin:
Neurological:
Psychiatric/Mental Health:
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Significant AND/OR abnormal Labs: |
Interpretation:
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Procedures, Surgeries or Treatments |
Interpretations/Results:
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IVF’s
1) IV solution ordered:
Rate ml/hr
Rationale for solution:
2) IV solution ordered:
Rate ml/hr
Rationale for solutions:
Drips
IV drip ordered:
Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.
Show calculations
Rationale for solution:
Show calculations
IV drip ordered:
Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.
Show calculations
Rationale for solution:
Show calculations
Rev 10/2021
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Medications: Brand & Generic Name |
Classification:
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Dosage/Route/Frequency:
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Side Effects:
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Nursing Considerations:
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Nursing Diagnosis: (NANDA) Physical (1)
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Planning/Outcome Goal
Short Term:
Long Term:
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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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Nursing Di)agnosis: (NANDA) Physical (2)
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Planning/Outcome Goal
Short Term:
Long Term:
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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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Nursing Diagnosis: (NANDA) Psychosocial (1)
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Planning/Outcome (Goal)
Short Term:
Long Term:
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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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Nursing Diagnosis: (NANDA) Psychosocial (2)
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Planning/Outcome (Goal)
Short Term:
Long Term: |
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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Medical Diagnosis:
Pathophysiology of disorder:
References
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.
______ _____________________________________________________________________________________________________
