2
Patient Care Plan
Student Name
Ana G. Mendez University
Class Name
Rachel Quintana, RN, BSN
Date
Patient Demographics
| Patient Initials: | Age: | ||||
| Sex: | Culture/Ethnicity: | ||||
| Allergies: | Weight: | Height: | BMI: | ||
| Code Status: | Language: | ||||
| Occupation: | Marital Status: | ||||
| Current work status: | Highest grade completed: | ||||
| Blood Pressure: | Heart Rate: | Respiration Rate:
|
Temperature:
|
Oxygen Saturation:
|
Pain:
(include scale used) |
Health History
History of present illness:
Past Medical History:
Surgical History:
Social History:
Diagnostic procedures:
Surgical procedures:
Labs:
Diet with rationale:
Activity order:
Limitations/prosthetic devices:
Current medications:
Nursing Diagnoses
Nursing Diagnosis 1
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Diagnosis 2
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Diagnosis 2
R/T:
AEB:
Rationale: Should support the nursing diagnosis
Nursing Interventions
Nursing Diagnosis 1
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Nursing Diagnosis 2
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Nursing Diagnosis 3
· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.
Evaluation
Explain if and how the interventions worked for the patient.
Discharge Planning
Write a discharge plan for this patient.
Pathophysiology
Write a brief summary regarding this patient’s main diagnosis as if you were explaining it to the patient.
References
References should be no older than 5 years and in APA 7 format.
Certainly! Below is a template for your patient care plan based on the structure you provided. You can fill in the details specific to your patient case.
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# Patient Care Plan
**Student Name:**
Ana G. Mendez University
Class Name
Rachel Quintana, RN, BSN
Date
## Patient Demographics
– **Patient Initials:** [Enter patient initials]
– **Age:** [Enter age]
– **Sex:** [Enter sex]
– **Culture/Ethnicity:** [Enter culture/ethnicity]
– **Allergies:** [List any allergies]
– **Weight:** [Enter weight]
– **Height:** [Enter height]
– **BMI:** [Calculate and enter BMI]
– **Code Status:** [Enter code status, e.g., Full Code, DNR]
– **Language:** [Primary language spoken by patient]
– **Occupation:** [Enter occupation]
– **Marital Status:** [Enter marital status]
– **Current work status:** [Enter work status, e.g., employed, unemployed, retired]
– **Highest grade completed:** [Enter highest grade or level of education]
– **Vital Signs:**
– **Blood Pressure:** [Enter BP reading]
– **Heart Rate:** [Enter HR]
– **Respiration Rate:** [Enter RR]
– **Temperature:** [Enter temp]
– **Oxygen Saturation:** [Enter O2 saturation]
– **Pain:** [Enter pain level, include scale used]
## Health History
– **History of present illness:** [Describe the current illness]
– **Past Medical History:** [List past medical history]
– **Surgical History:** [List any surgeries the patient has undergone]
– **Social History:** [Include relevant social history, e.g., smoking, alcohol use, support system]
– **Diagnostic procedures:** [List any diagnostic tests performed]
– **Surgical procedures:** [List any surgeries]
– **Labs:** [Include relevant lab results]
– **Diet with rationale:** [Specify dietary orders and rationale]
– **Activity order:** [Specify activity orders, e.g., bed rest, ambulation]
– **Limitations/prosthetic devices:** [Note any limitations or use of prosthetics]
– **Current medications:** [List all medications patient is currently taking]
## Nursing Diagnoses
### Nursing Diagnosis 1
– **R/T:** [Related factors]
– **AEB:** [As evidenced by, include specific symptoms/observations]
– **Rationale:** [Support the nursing diagnosis with evidence/rationale]
### Nursing Diagnosis 2
– **R/T:** [Related factors]
– **AEB:** [As evidenced by, include specific symptoms/observations]
– **Rationale:** [Support the nursing diagnosis with evidence/rationale]
### Nursing Diagnosis 3
– **R/T:** [Related factors]
– **AEB:** [As evidenced by, include specific symptoms/observations]
– **Rationale:** [Support the nursing diagnosis with evidence/rationale]
## Nursing Interventions
### Nursing Diagnosis 1
– [Interventions done to assist the patient]
### Nursing Diagnosis 2
– [Interventions done to assist the patient]
### Nursing Diagnosis 3
– [Interventions done to assist the patient]
## Evaluation
– [Explain if and how the interventions worked for the patient, including any improvements or changes]
## Discharge Planning
– [Write a detailed discharge plan, including patient education, follow-up care, medications, diet, activity, and any referrals]
## Pathophysiology
– [Provide a brief, patient-friendly summary of the main diagnosis, explaining it in layman’s terms]
## References
– [List references here in APA 7th edition format, ensuring they are no older than 5 years]
—
You can use this template to organize your patient care plan effectively. Make sure to fill in each section with accurate and specific information related to the patient you are working with.
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