Care Plan essay paper

Care Plan

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STUDENT NAME: DATE:

CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES:  Advance Directives: Restrains: Y / N DIET (including tube feeding with rate)

Admitting Medical Diagnosis:

Chief Complaint:

History of Present illness:

Past Medical History:

Cultural and Spiritual Assessment:

Care Plan

 

Medications taken at home or before transfer: (include dose and frequency)

 

 

Summarize Pathophysiology (in our own words, include definition, etiology and physiology)
Definition of Concurrent Diagnoses (all of them)	Correlational of all diagnoses with current condition

 

Care Plan

Signs and Symptoms: (Indicate which ones your client has)	Diagnostic test for this condition: (Indicate which ones  utilized for client)
Treatment (med/surg/pharmacological)	Nursing Interventions and rationale:

 

 

 

 

 

 

 

 

 

 

 

 

Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.

Generic/Trade Name Classification	Major Action Reason Prescribed to Client	Dose Given/Normal  Range	Adverse Effects Precautions/Contraindications	Nursing Implication
				.

 

Care Plan

Generic/Trade Name  Classification	Major Action Reason Prescribed to  Client	Dose Given/  Normal Range	Adverse Effects  Precautions/Contraindications	Nursing Implication

 

 

Generic/Trade Name  Classification	Major Action Reason Prescribed to  Client	Dose Given/  Normal Range	Adverse Effects  Precautions/Contraindications	Nursing Implication

 

 

LABORATORY AND DIAGNOSTIC TESTS

 

 

 

 

 

 

 

 

 

 

 

 

Other Pertinent labs

DATE	DIAGNOSTIC STUDY	RESULTS	SIGNIFICANCE TO PATIENT

 

 

 

 

 

 

 

 

 

 

 

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS	SCIENTIFIC PRINCIPLE/  RATIONALE	EVALUATION	MODIFICATION

 

 

 

 

 

 

 

NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS	SCIENTIFIC PRINCIPLE/  RATIONALE	EVALUATION	MODIFICATION

 

 

DISCHARGE PLANNING

CLIENT’S NEED FOR DISCHARGE	INTERVENTIONS	RATIONALE