4 Care Plans

CARE PLAN WORKSHEET

Student’s Name:
Date/Time:
Client’s Initials:
Admission Date:
Age:
Sex:
Race:
Religion:
Allergies:
Diet:
Activity:
Admitting Medical Diagnosis:
Past Medical History:
Past Surgical History:
History of Present Illness:
Client Understanding of Illness:

PATHOPHYSIOLOGY

What Medications are you currently taking at home?

Are your medications causing you any discomfort?

OVERVIEW MEDICATION(S) WORKSHEET (TOPICAL, PO, IM, SQ, IV)

NAME/CLASSIFICATION	DOSE/ROUTEFREQUENCY SAFE RANGE	MECHANISM OF ACTION	INDICATIONS	SIDE EFFECTS	NURSING CONSIDERATIONS AND PATIENT EDUCATION

OTHER LABS:

Relate the clinical significance of abnormal lab values above:

Abnormal Lab Value	Explain why lab value is abnormal

DIAGNOSTIC PROCEDURES

NURSING CARE PLAN

Assessment Subjective/Objective Date	Priority Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/ Objectives	Nursing Interventions/Actions/Orders and Rationale	Evaluation

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