Nursing Care Plan


Nursing Care Plan:
History of present illness including admission diagnosis & chief complaint (normal & abnormal) supported by evidence-based citations
physical assessment findings including presenting signs and symptoms supported with evidence-based citations
relevant diagnostic procedures/results & pertinent lab tests/values (with normal ranges) include dates and rationales supported with evidence-based citations
past medical & surgical history, pathophysiology of medical diagnoses (include dates, if not found state so) supported by evidence-based citations
Erikson’s developmental stage with rationale and supported by evidence-based citations
socioeconomic/cultural/spiritual orientation & psychosocial considerations/concerns supported with evidence-based citations (3 lists)
Potential health deviation, predisposing & related factors (at least two) include three independent nursing interventions for each (“at risk for… ” nursing dx)
Inter-professional consults, discharge referrals, and current orders (include diet, test, and treatments) with rationale supported with evidence-based citations
Priority nursing diagnosis (at least 2) written in three-part statement