Nursing Care Plan

CONCEPT MAP

 

 

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History of Present Illness (HPI)

 

 

 

 

 

Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (3)

 

 

 

 

 

 

 

 

 

 

 

 

Pathophysiology of Medical History (3)

 

 

 

 

 

 

 

 

Surgical History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social History

Patient Info (1)

Name:

Age:

Gender:

Code Status:

DPOA:

Living Will:

Allergies:

 

 

 

Erickson’s Developmental Stage Related to pt. & Cite References (1)

 

Chief Complaint

 

 

 

 

Admitting Diagnosis

 

 

 

 

 

Concept Map

Student Name:

Instructor: Blackard

 

 

 

 

Medical Management/ Orders/ Medications & Allergies (2)

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Management/ Orders/ Medications & Allergies

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Management/ Orders/ Medications & Allergies

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Management/ Orders/ Medications & Allergies

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

 

 

 

Cultural considerations, ethnicity, occupation, religion, family support, insurance.

 

Diagnostic Test/ Lab Results with dates and Normal Ranges

Test

Norms

Date

 

Current Value

WBC

4.40-11

 

 

Hgb

14.0- 16.0

 

 

Hct

36-42

 

 

Platelets

150-450

 

 

Na+

135-145

 

 

K+

3.5-5.0

 

 

Creatinine

0.6-1.3

 

 

Blood Glucose

76-106

 

 

BUN

8.0-30.0

 

 

Troponins

0.0-0.4

 

 

BNP

>125pg/mL

 

 

ALT

7 to 56

 

 

Ca+

8.5 – 10.5

 

 

Albumin

3.5 – 5.5

 

 

AST

10- 40

 

 

Blood cultures

 

 

 

Cholesterol

100 to 129

 

 

Triglycerides

 

 

 

HDL

40 – 59

 

 

LDL

100 -129

 

 

 

 

 

 

 

 

 

 

 

Neurological

 

 

 

Vital Signs (4)

 

 

 

 

 

Cardiovascular

 

 

 

 

Respiratory

 

 

 

 

 

 

Rest/Exercise

 

 

 

 

Nutrition/Hydration

 

 

 

 

 

Misc. (Ht/Wt)

 

 

 

Integumentary

 

 

GI

 

 

 

 

 

 

GU

 

 

 

 

Psychosocial (14)

 

 

 

 

Endocrine

 

 

 

 

 

Patient Education (In Pt.) & Discharge Planning (home needs )

Patient Education while in patient:

Discharge Planning/Education:

 

 

 

Priority nursing diagnosis #1

 

 

 

Priority nursing diagnosis #1

 

 

 

 

 

 

 

 

 

 

 

 

 

Outcome/Goal #1

 

 

 

 

Outcome/Goal #2

 

 

 

 

 

 

 

 

 

 

 

Interventions #1

 

 

Assessment/ Evaluation #1

 

Interventions # 2

 

 

Assessment/ Evaluation #2

 

 

 

 

 

 

PC Outcomes/Goal

 

 

.

 

PC Interventions

 

 

 

 

 

Potential Complications/ at risk for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PC Evaluation Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References: