Section I
General Data
(Points 5)
 
Chief Complaint:
 
 
History of Present Illness (Detailed):
 
 
 
Past Medical/Surgical History:
 
 
 
Social History:
 
 
 
Family History of Illness:
 
Immunization History:
 
 
Description of Procedures (Surgeries) Performed this Admission:
 
 
 
 
Section II
Pathophysiology
(Points 10)
 
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan )
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Section III
Assessment
(Points 20)
 
Physical Assessment:
 
General Appearance
 
 
Neurosensory
 
 
Psychosocial
 
 
Cardiovascular
 
 
Respiratory
 
 
Gastrointestinal
 
 
Genitourinary
 
 
Musculoskeletal
 
 
Integumentary
 
 
 
Incisions
 
 
Drains
 
 
Diet/Nutrition
 
 
IVs
 
 
Vital Signs
 
 
Intake and Output
 
Pain assessment (include reassessment)
 
 
Fall Risk Assessment (include score)
 
 
Pressure Ulcer Risk Assessment (include score)
 
 
 
Section IV
Diagnostic Data
(Points 10)

 
Section V
Treatment and procedures
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
(Points 10)

 
Section VI
Teaching and Health Promotion
(Points 5)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
 
1)
 
2)
 
3)
 
4)
 
5)
 
 
 
 
 
 
Section VII
 (Points 5)
List of Nursing Diagnoses Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)
 
1)
 
 
2)
 
 
3)
 
 
4)
 
 
 
Section VIII
Medications
(Points 10)
Medication Sheet
 

 
 
 
 
 
Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES