NURSING CARE PLAN

Patient’s Initials: _____________ Chief Complaint: Name of Student Nurse:

Age & Gender: _______________
Birthdate:
____________________________________
Address:
____________________________________
____________________________________
__________________________________
Admitting
Diagnosis:_________________________
__________________________________
Date of Confinement:
______________________________
___________________________
Level/Block/Group:
____________________________
Hospital/Area:
____________________________
Clinical Instructor: __________
Date: _______

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

ANALYSIS

Subjective:  deficient After 3 hours -Explore concerns -Provides After 3 hours of

 Using Knowledge of nursing regarding opportunity to nursing intervention
condoms [Learning intervention childbearing and correct the patient is able to
occasionally, Need] the patient will family planning. misconceptions and Verbalize
when she regarding -Verbalize present information understanding of
“needs them.” disease, understanding necessary to make goals of treatment.
 She has had 2 prognosis, of goals of informed decisions Initiated necessary
lifetime treatment. lifestyle changes.
treatment,
partners. -Discuss family Various antiretroviral
self-care, Initiate Participated in
 she last had planning issues drugs have differing
and necessary treatment regimen.
unprotected and careful effects on ethinyl
intercourse 3 discharge lifestyle
selection of oral estradiol (EE), either -patient exhibit a
days ago and needs changes.
contraceptives. enhancing or normal blood
is worried she related to Participate in
decreasing pressure of 120/80
might get Unfamiliarity treatment
 pregnant. with regimen. protective mm hg.
 sexually active information effectiveness.
-exhibit blood
at age resources.
pressure -These behaviors
15 and had AEB Reports -Encourage
within normal and substances
sex with her the problem. identification and
range have direct adverse
first partner 3- reduction of
effects on
4 times but individual risk
cardiovascular
didn’t use factors such as
function and may
contraception. smoking, alcohol
impede recovery,
 She has never consumption, and
increase risk for
obesity.
had a Pap complications.
smear or -Identify services
Provides for ongoing
Pelvic exam. and resources
monitoring,
 She smokes available after
continutation of
one-half pack discharge.
prescribed
of cigarettes therapies, and
per day, drinks support for lifestyle
alcohol changes.
socially, and
uses
occasional
marijuana.

Objective
 BP: 100/60
 P: 68
 R: 20
 T: 36.5