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  • Care Plan

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    Erica Clipps
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    This nursing process worksheet contains sections for documenting information about a patient such as their history, assessment findings, problems, goals, interventions, and evaluation. The worksheet includes spaces for the patient's initials, age, gender, history of present illness, past medical/surgical history, subjective and objective assessment findings, problem list, short and long term goals, 5 interventions with rationale, evaluation parameters, and medication list with relevant details. The document provides a structured format for nurses to record and plan care for a specific patient.

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    Care Plan Doc

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    This nursing process worksheet contains sections for documenting information about a patient such as their history, assessment findings, problems, goals, interventions, and evaluation. The worksheet includes spaces for the patient's initials, age, gender, history of present illness, past medical/surgical history, subjective and objective assessment findings, problem list, short and long term goals, 5 interventions with rationale, evaluation parameters, and medication list with relevant details. The document provides a structured format for nurses to record and plan care for a specific patient.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    2 views3 pages

    Care Plan

    Uploaded by

    Erica Clipps
    This nursing process worksheet contains sections for documenting information about a patient such as their history, assessment findings, problems, goals, interventions, and evaluation. The worksheet includes spaces for the patient's initials, age, gender, history of present illness, past medical/surgical history, subjective and objective assessment findings, problem list, short and long term goals, 5 interventions with rationale, evaluation parameters, and medication list with relevant details. The document provides a structured format for nurses to record and plan care for a specific patient.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    SOUTHUNIVERSITYCOLLEGEOFNURSING

    NursingProcessWorksheet
    STUDENT:______________________________________
    PatientInitials:___________

    Age:____________

    NSG_____

    FACULTY______________________

    Gender:______

    HistoryofPresentIllness/AdmittingDiagnosis(whathappenedthatbroughtthemin,whathashappenedsince,subsequentdiagnosis)
    PastMedical/SurgicalHistory
    Medical:
    Surgical:

    Assessment:
    Subjectivefindings

    Objectivefindingsbecomprehensiveinyourassessmentfindings
    - General/VS:
    - Neuro:
    - Resp:
    - Cardiac:
    o IVAccess:
    o Fluids/Drips:
    - GI:
    - GU:
    - Skin:
    - Psychosocial/Family:
    - PertinentLabs/Radiology/otherexams:

    ProblemList:

    Nursing Process Worksheet Winter 2012 LS

    PriorityNursingDiagnosis

    Outcomes/Goals(whatdoyouwanttohappen):
    ShortTerm

    LongTerm

    Interventions(howareyougoingtomakeithappen)ANDtherationale:****5interventions****
    Placeanasterisk*bytheinterventionsthatmaybecarriedoutbythoseotherthananRN
    1.

    Evaluation(didithappen):
    Providetheparametersthatwillbeusedtoevaluatewhether,ornot,theoutcomehasbeenachieved

    Nursing Process Worksheet Winter 2012 LS

    Medication List: ***List medication that relates to the medical or nursing diagnosis***

    Name of drug with dose


    Drug class
    Indication for this patient
    Possible side effects for this patient
    Pertinent nursing considerations and areas to monitor

    Nursing Process Worksheet Winter 2012 LS

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