2
Patient Care Plan
Student Name
Ana G. Mendez University
Class Name
Rachel Quintana, RN, BSN
Date
Patient Demographics
Patient Initials: | Age: | ||||
Sex: | Culture/Ethnicity: | ||||
Allergies: | Weight: | Height: | BMI: | ||
Code Status: | Language: | ||||
Occupation: | Marital Status: | ||||
Current work status: | Highest grade completed: | ||||
Blood Pressure: | Heart Rate: | Respiration Rate: | Temperature: | Oxygen Saturation: | Pain: (include scale used) |
Health History
History of present illness:
Past Medical History:
Surgical History:
Social History:
Diagnostic procedures:
Surgical procedures:
Labs:
Diet with rationale:
Activity order:
Limitations/prosthetic devices:
Current medications:
Nursing Diagnoses
Nursing Diagnosis 1
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Diagnosis 2
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Diagnosis 2
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Interventions
Nursing Diagnosis 1
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Nursing Diagnosis 2
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Nursing Diagnosis 3
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Evaluation
Explain if and how the interventions worked for the patient.
Discharge Planning
Write a discharge plan for this patient.
Pathophysiology
Write a brief summary regarding this patient’s main diagnosis as if you were explaining it to the patient.
References
References should be no older than 5 years and in APA 7 format.
