Care_Plan_template.

NURSING PROCESS CAREPLAN

 

MEDICAL PREP INSTITUTE OF TAMPA BAY COURSE NAME:

 

 

 

INSTRUCTOR:

 

STUDENT NAME:

 

ASSIGNMENT DATE:

 

 

 

MEDICAL PREP INSTITUTE OF TAMPA BAY Nursing Process Care Plan

Client Initials: Culture/Ethnicity: Support System:

Unit: Room/Bed: Religion: Occupation:

Age: Sex: Language: Current Work Status:

Weight: Height: Marital Status: Highest Grade Completed:

Primary Patient Complaint: Patient Medical History:

Diagnostic Procedures (Not to include labs):

 

Surgical Procedures:

Pathophysiology/Etiology (Theory): Define patient primary problem and cause(s).

Supporting Symptomatology: What patient data supports your selection of Pathophysiology?

Developmental Stage (Theory): Utilize Erikson. Identify what stage is applicable to your patient based on their age.

 

Developmental Stage (Actual): Identify what developmental stage your patient is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage.

 

Vital Signs/Frequency:

 

 

 

LAB RESULTS INTERPRETATION

PATIENT’S LAB RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS

 

 

 

 

 

 

 

 

DIAGNOSTIC RESULTS INTERPRETATION

PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS

 

 

 

 

 

 

 

 

 

 

ASSESSMENT Subjective/ Objective

NURSING DIAGNOSIS

#1 (Physical)

PLANNING/ OUTCOME

(Client Centered) 1 Short Term 1 Long Term

INTERVENTIONS (Nurse Centered)

1 Monitoring, 1 Action & 1 Teaching per Goal

RATIONALE FOR INTERVENTIONS

1 per Intervention

EVALUATION (Evaluate each

Goal)

 

 

 

 

 

 

 

 

 

ASSESSMENT Subjective/ Objective

NURSING DIAGNOSIS

#2 (Physical)

PLANNING/ OUTCOME

(Client Centered) 1 Short Term 1 Long Term

INTERVENTIONS (Nurse Centered)

1 Monitoring, 1 Action …