1260 SVN Clinical Care Plan Student: Nina Nicholson Clients Initials: Age: Sex: Date(s) of Care: Education:

Occupation: Date of Admission: Primary Physician: Consulting Physicians: Score

Ethnicity: Diet: Marital Status (circle): Ht: Wt: S M W D Religion: Vital Signs: PRAdmitting Diagnosis (define & list textbook signs & symptoms):

Allergies:

BP:

T-

_____/10

_____/10 Medical History (Diagnoses): Define- 1. 2. 3. ______/4 Lab Result Normal Values Reason for Abnormal Lab Results

_____/16 Score ___________

ASSESSMENT Visual assessment ie: O2, catheter care-routine & PRN given in last 24 hours

PRIORITIZED NANDAS Place in order of importance

1.

GOALS Trend Realistic Measurable

1. 2. 3. 4.

INTERVENTIONS (must related to your goals)

EVALUATION Goals cannot be evaluated until after taking care of the patient

Score:_____/6 2.

Score: ______/6 1. 2. 3. 4.

Score:______/8

Score:_____/6

Score: ______/6

Score:______/8

3.

1. 2. 3. 4.

Score:____/6

Score: ______/6

Score:______/8