NURSING CARE PLAN TEMPLATE

NURS 101L, NURS 210L-AB, NURS 317L

Student

   Date  
Instructor   Course  
Patient Initial   Unit/ Room#   DOB  
Code Status   Height/Weight  
Allergies  

 

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
 

 

          

 

 

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

 Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
 

 

 

 

  

 

 

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

 

 Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations
 

 

 

 

  

 

 

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

 Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations
 

 

 

 

  

 

 

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

 Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations
 

 

 

 

 

  

 

Signs and

Symptoms

 

As evidenced by

 

Related to

Contributing

Factors

Diagnostic

Label

 

 

 

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

 

 Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

 

 Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

 Rationale Each must be

supported with Evidence Based Citations

 Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

 
         
         
         
         
         
         

 

 

MEDICATION LIST

 

Medications (with APA citations Class/Purpose Route Frequency Dose (& range)

If out of range, why?

 Mechanism of action

Onset of action

 Common side effects Nursing considerations

specific to this patient
               
               
               
               
               

 

 

Revision Date: Month, Year (i.e. February, 2010) Page 1