Learning Goal: I’m working on a nursing project and need an explanation and answer to help me learn.

Fill out the nursing care plan with a case of a patient

NEW PROFESSIONS TECHNICAL INSTITUTE
4000 West Flagler Street Miami, Florida 33134
(305) 461-2223 / Fax: (305) 461-3029
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:
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
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
.
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 BYSubjective Supportive DataObjective Supportive Data
NURSING ACTIONS SCIENTIFIC PRINCIPLE/
RATIONALE
EVALUATION MODIFICATION
NURSING DIAGNOSIS R/T AND EVIDENCED BYSubjective Supportive DataObjective Supportive Data
NURSING ACTIONS SCIENTIFIC PRINCIPLE/
RATIONALE
EVALUATION MODIFICATION
DISCHARGE PLANNING
CLIENT’S NEED FOR DISCHARGE INTERVENTIONS RATIONALE

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