DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Nursing Care Plan Form

Students Name: _______________________________________

Date: _______________________________

Time: ___________________________

Clients Initials: _______________________________________

Sex: ________________________________

Admission Date: __________________

D.O.B.: _______________________________________________

Age: ________________________________

Race: ___________________________

Allergies: ________________________________________________________________________________________________________________________

Admitting Medical Diagnosis (es):

__________________________________________________________________________________________________________________________________
Surgical Procedure (s) (include date):
__________________________________________________________________________________________________________________________________
What brought you to the Institution (Hospital, Home?)
__________________________________________________________________________________________________________________________________
History of present illness:
__________________________________________________________________________________________________________________________________
Clients Understanding of Illness:
__________________________________________________________________________________________________________________________________
Past medical history:
__________________________________________________________________________________________________________________________________
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1/11/2012

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

What Medications are you currently taking, when/why?

Medication(s)

Time

Why

1
2
3
4
5
6
7
8
9
10
11
12

Are your medication(s) causing you discomfort? If yes, please explain.

________________________________________________________________________________________________________________________

______________________________________________________________________________________________________

_____________________________________________________________________________________BBB_
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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Medications: (Topical; PO; IM; sub Q; IV)

Name/Dose
Safe/ Range

Mechanism of Action

Indication(s)

Side Effects

Nursing Consideration(s)

Route/Frequency

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Medications: (Topical; PO; IM; sub Q; IV)

Name/Dose
Safe/ Range

Mechanism of Action

Indication(s)

Side Effects

Nursing Consideration(s)

Route/Frequency

NRF1036

1/11/2012

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Lab Values
Chemistry
Sodium
Potassium
Chloride
C02
Calcium
Phosphorus
Cholesterol
Albumin
T-Protein
Bun
Creatinine
Magnesium
Uric Acid
Biliburin
Amylase
Lipase
LDH
HDL
LDL
Urinalysis
Color
Turbidity
SG
PH
Glucose
Ketone
NRF1036

Normal Value

Clients Value

Date

Hematology

Normal Value

Clients Value

Date

RBC
HGB
HTC
MCV
MCH
MCHC
WBC
Neurophils
Bands
Segments
Eosinophils
Basophils
Lymphocytes
Monocytes
Plat
Coagulation
Normal studies
PT
PTT
Prothrombin Time
Bleeding Time

Test(Normal)

TSH
Bun/creat
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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Chemistry

Normal Value

Clients Value

Date

Hematology

Blood

Osmolality

Protein

RDW

Bilirubin

MPV

Urobilinogen

AIC-Hgb

Nitrate

ALT(SGPT)

Leukocytes

AST(SGOT

Cast

T.bilirubin

Normal Value

Clients Value

Date

RBC
Crystals

HDL

WBC

LDL

Epithelial Cells

VLDL
CHOL/HDL

Miscellaneous

Relate the clinical significance of abnormal lab values above:

_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
NRF1036

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Diagnostic Tests
RESULTS (Please include date of tests results)

X-RAYS/ CT SCAN/ US/MRI/EKG etc

NRF1036

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Brief Textbook Picture

(Include etiology, pathophysiology, signs & symptoms, medical treatments, prognosis, etc. Compare to Client)

Textbook

NRF1036

Compare to Client

1/11/2012

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Brief Textbook Picture

(Include etiology, pathophysiology, signs & symptoms, medical treatments, prognosis, etc. Compare to Client)

Textbook

NRF1036

Compare to Client

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

Stage of Development
Describe the Clients stage of development according to Piaget, Freud or Eriksons Theory. Compare the developmental stage to the client
Theory

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Client

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

NURSING CARE PLAN

Assessment

Nursing Diagnosis

Short-term Goals

Long-term Goals

Subjective Data:

Objective Data:

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

NURSING CARE PLAN (Continuation)

Nursing
Interventions/Implementation

NRF1036

Scientific Rationales

Evaluation

1/11/2012

Modification

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DADE MEDICAL COLLEGE

NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.

NURSING CARE PLAN (Continuation)

Nursing
Interventions/Implementation

NRF1036

Scientific Rationales

Evaluation

1/11/2012

Modification

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