2
Patient Care Plan
Student Name
Ana G. Mendez University
Class Name
Rachel Quintana, RN, BSN
Date
Patient Demographics
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Patient Initials: |
Age: |
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Sex: |
Culture/Ethnicity: |
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Allergies: |
Weight: |
Height: |
BMI: |
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Code Status: |
Language: |
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Occupation: |
Marital Status: |
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Current work status: |
Highest grade completed: |
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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.
