Section I
General Data
(Points 5)
Chief Complaint:
History of Present Illness (Detailed):
Past Medical/Surgical History:
Social History:
Family History of Illness:
Immunization History:
Description of Procedures (Surgeries) Performed this Admission:
Section II
Pathophysiology
(Points 10)
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan )
Section III
Assessment
(Points 20)
Physical Assessment:
General Appearance
Neurosensory
Psychosocial
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Incisions
Drains
Diet/Nutrition
IVs
Vital Signs
Intake and Output
Pain assessment (include reassessment)
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Section IV
Diagnostic Data
(Points 10)
| Diagnostic Tests | Patient’s value | Normal Range | Inference(why is this patients value abnormal) |
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Section V
Treatment and procedures
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
(Points 10)
| Interventions | Rationale |
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Section VI
Teaching and Health Promotion
(Points 5)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
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5)
Section VII
(Points 5)
List of Nursing Diagnoses Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)
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Section VIII
Medications
(Points 10)
Medication Sheet
| Medication Dose
Brand/ Generic Name |
Mechanism of Action/Indication for Use | Contraindication | Adverse Effects/Side Effects | Nursing Implications
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Outcomes | Safe Dose
(yes or no) Why is your client on the drug? |
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Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES
| Assessment
findings |
Nursing Diagnosis
(Actual & Potential Deficits, Wellness Diagnoses) |
Outcomes
Short and Long Term |
Interventions/Nursing Systems
(Dependent & Independent) |
Rationale
(Why are performing that intervention?) |
Evaluation/Outcome
(What was the actual result?) |
