STUDENT CARE PLAN

Student: Date:
Patient/Client Initials: M/F:
Dates Cared for: Rm. #:
Date of Admission: Physician:
Medical Diagnosis: Pertinent Past History:
Surgery (if any) and Date: Health Insurance:
Marital Status:

Pathophysiology of admitting diagnosis (diagnoses): (4 points)

Revised 5/99 Pathophysiology Reference Source(s):

Nursing Assessment Criteria - (2 points) From the pathophysiology textbook or components of Medical-Surgical
text.

SUBJECTIVE:

OBJECTIVE:

PSYCHOSOCIAL:

RISK FACTORS: For acquiring the disease or condition. (May be found under etiology).

Ref:
 GORDON'S FUNCTIONAL HEALTH PATTERNS
STUDENT ASSESSMENT GUIDE (22 points)

#1 HEALTH MAINTENANCE MGMT. SUBJECTIVE OBJECTIVE

Admit Date

Medical Diagnosis

Pertinent medical history

Pertinent psychosocial history

Insurance

Age

Allergies-Food and medicines

Erikson's Developmental Level

Tendency toward which pole

Perception of health status

Immunization status

Risk behaviors

Discharge needs

Medications prior to admission

#2 NUTRITION/METABOLIC SUBJECTIVE OBJECTIVE

Diet

Recent intake (% of meals)

Food preferences

Abdomen

Bowel sounds

Nausea

NG Tube

IV Fluids

Intake/Output (no. of hours)

Temperature

Edema

Height, Weight

Body Mass Index

#3 ELIMINATION SUBJECTIVE OBJECTIVE
Bladder

Bowel patterns

Last BM

Skin

Braden scale score

#4 ACTIVITY/EXERCISE SUBJECTIVE OBJECTIVE

Respiratory - Rate
Character of respirations

Color

Breath sounds

SpO2

Cardiac
Apical pulse (rate, rhythm, sounds)

Peripheral pulses

Capillary refill time

Blood pressure

Homan's sign

ROM

Mobility (describe extent)

Assistive equipment

ADL performance

Leisure and recreation

#5 COGNITIVE/PERCEPTUAL SUBJECTIVE OBJECTIVE

Pain (scale, characteristics)

Glasgow score

Sensory aids

Level of consciousness

Circulation, Motion, Sensation (CMS)

#6 SLEEP/REST SUBJECTIVE OBJECTIVE

Pattern of Sleep

Quality/Quantity
#7 SELF-PERCEPTION/SELF-ESTEEM SUBJECTIVE OBJECTIVE
Describes attitudes about self
and perception of abilities.

Attitudes about self

Impact of illness on self

Desire to change self

Nervous or relaxed: rate 1-5

Perceived powerlessness

Body posture

Eye contact

Assertive or passive: rate 1-5

Nonverbal cues to altered self-esteem

Facial expressions

#8 ROLE/RELATIONSHIP SUBJECTIVE OBJECTIVE

Occupation

Recent change in Role

Comfort with Change

Marital Status

Family structure

#9 SEXUALITY SUBJECTIVE OBJECTIVE

Menstrual history: children

Self-breast/testicular exams

Impact of illness on sexuality

Birth control

#10 COPING/STRESS SUBJECTIVE OBJECTIVE

Expression of stress

Stressors

Usual coping mechanisms

Support systems

Family support

Community resources
#11 VALUE/BELIEF SUBJECTIVE OBJECTIVE
Religious Preference

Spirituality

Cultural beliefs and practics

Practice of values/beliefs

Advanced directives

DNR
 STUDENT CARE PLAN

Laboratory Diagnostic Studies (2 points) - Relevant at this time:

DATE TEST NORMAL VALUE PATIENT/CLIENT VALUE REASON FOR TEST, SIGNIFICANCE OF ABNORMAL RESULTS FOR THIS PATIENT

Reference:

Radiological Diagnostic Studies - Relevant at this time.

DATE TEST FINDINGS, SIGNIFICANCE FOR THIS PATIENT

Reference:
 MEDICATION WORKSHEET - (5 POINTS)

CLASSI- MEDICA- USUAL

FICATION TION DOSAGE ROUTE MECHANISM OF ACTION DRUG INTERACTIONS TOXIC/SIDE EFFECTS NURSING INTERVENTIONS
Current medical orders that form the basis for collaborative care: (1 point)
 ARENA ASSESSMENT - (3 points)

How does each arena contribute to physical and psychosocial-spiritual well-being?

A. Agency
a. Physical

b. Psychosocial-spiritual

B. Family
a. Physical

b. Psychosocial-spiritual

C. Community
a. Physical

b. Psychosocial-spiritual
 STUDENT CARE PLAN WORKSHEET – (6 points)

RATIONALE FOR
WEAKNESSES PRIORITIZE THREE AREAS OF CARE
PRIORITIZATION OF PROBLEMS
Prioritize for Care AND STATE EACH PROBLEM AS A
STRENGTHS DISCHARGE GOALS
Using Maslow’s Hierarchy of NANDA DIAGNOSIS
Needs
1.

2. _________________________________________
TEACHING NEEDS
_________________________________________

3.
 Student Name:

NURSING DIAGNOSIS Patient’s Medical Diagnosis:

DEFINITION:
2

p DEFINING
CHARACTERISTICS:
o

n
RELATED
t FACTORS:

s STUDENT In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
INSTRUCTIONS: Gordon’s Functional health Pattern.
A Subjective Data Entry (1 point) Objective Data Entry (1 point)
S
S
E
S
S
M
E
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
N
T
Time Out! related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
D PATIENT Nursing Diagnosis (specify)
I DIAGNOSTIC Related to
A STATEMENT:
(2 points)
G
N
O
S
I
S
DESIRED OUTCOME: (2 points)

A. INTERVENTION (2 points) B. RATIONALE (reference) (2 points) C. EVALUATION (2 points)

D. Sample documentation or charting of nursing care and patient response. (2 points)

E. Was the desired outcome achieved? (1 point)

 Student Name:

NURSING DIAGNOSIS Patient’s Medical Diagnosis:

DEFINITION:
2

p DEFINING
CHARACTERISTICS:
o

n
RELATED
t FACTORS:

s STUDENT In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
INSTRUCTIONS: Gordon’s Functional health Pattern.
A Subjective Data Entry (1 point) Objective Data Entry (1 point)
S
S
E
S
S
M
E
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
N
T
Time Out! related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
D PATIENT Nursing Diagnosis (specify)
I DIAGNOSTIC Related to
A STATEMENT:
(2 points)
G
N
O
S
I
S
DESIRED OUTCOME: (2 points) .

A. INTERVENTION (2 points) B. RATIONALE (reference) (2 points) C. EVALUATION (2 points)

D. Sample documentation or charting of nursing care and patient response. (2 points)

E. Was the desired outcome achieved? (1 point)

 Student Name:

NURSING DIAGNOSIS Patient’s Medical Diagnosis:

DEFINITION:
2

p DEFINING
CHARACTERISTICS:
o

n
RELATED
t FACTORS:

s STUDENT In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
INSTRUCTIONS: Gordon’s Functional health Pattern.
A Subjective Data Entry (1 point) Objective Data Entry (1 point)
S
S
E
S
S
M
E
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
N
T
Time Out! related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
D PATIENT Nursing Diagnosis (specify)
I DIAGNOSTIC Related to
A STATEMENT:
(2 points)
G
N
O
S
I
S
DESIRED OUTCOME: (2 points) example sentence to show the use of underlining.

A. INTERVENTION (2 points) B. RATIONALE (reference) (2 points) C. EVALUATION (2 points)

D. Sample documentation or charting of nursing care and patient response. (2 points)

E. Was the desired outcome achieved? (1 point)

REFERENCE PAGE