- PAUL’S SCHOOL OF NURSING
NURSING CARE PLAN TEMPLATE
Student Name: ______________________________________ Course/Section # ________________________________
Clinical Facility: ______________________________________
Clinical Instructor: ______________________________________
Client Initial (Last Name Initial only) ______________________________________
Date of Care: ______________________________________
Date Care Study Due: ______________________________________
Date Submitted: ______________________________________
Two nursing diagnoses: Nursing Diagnosis #1 and Nursing Diagnosis #2
Nursing Care Planning Books should be used.
Note significant results of Lab results and/or medical testing. Include EKG sheet or telemetry strip if on monitoring.
Medical History: ______________________________________________________________________________________
Surgical History: ______________________________________________________________________________________
Admitting Diagnosis: ______________________________________________________________________________________
Subjective Data
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Objective Data
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
|
ASSESS |
PLAN: EXPECTED OUTCOME |
NURSING INTERVENTION |
RATIONALE FOR INTERVENTION (CITE SOURCES) |
EVALUATE (Progress toward outcome)
|
|
NURSING DIAGNOSIS 1
|
SHORT TERM:
1)
2)
LONG TERM:
1)
2)
|
1)
2)
3)
4)
5)
1)
2)
3)
4)
5) |
1)
2)
3)
4)
5)
1)
2)
3)
4)
5) |
SHORT TERM: 1)
2)
LONG TERM:
1) Unable to meet. Not present at discharge.
2) Unable to meet. Not present at discharge. |
|
ASSESS |
PLAN: EXPECTED OUTCOME |
NURSING INTERVENTION |
RATIONALE FOR INTERVENTION (CITE SOURCES) |
EVALUATE (Progress toward outcome)
|
|
NURSING DIAGNOSIS 2
|
SHORT TERM:
1)
2)
LONG TERM:
1)
2)
|
1)
2)
3)
4)
5)
1)
2)
3)
4)
5) |
1)
2)
3)
4)
5)
1)
2)
3)
4)
5) |
SHORT TERM: 1)
2)
LONG TERM:
1) Unable to meet. Not present at discharge.
2) Unable to meet. Not present at discharge. |
MEDICATIONS
List all medications prescribed for your patient and do drug cards (5) on the most relevant medications.
Drug cards should be completed for at least 5 of the patient’s medications. List all of the medications and how they relate to the patients Diagnosis[s]. Consult your clinical instructor if you need further instructions on proper format for drug cards.
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