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    RN Program Clinical Physical Assessment and Care Plan: Mark N/a If Not Applicable)

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    Virginia Amber Lindahl
    This document contains a template for a nursing student to complete a clinical physical assessment and care plan. It includes sections for demographic data, chief complaint, medical history, physical assessment, medications, lab results, medical diagnoses, nursing diagnoses, and a nursing care plan. The nursing care plan requires the student to prioritize 3 nursing diagnoses, include expected outcomes, 3 interventions for each diagnosis with rationales, and an evaluation section. The document provides a grading rubric to evaluate students' completion of the required sections.

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    RN Program Clinical Physical Assessment and Care Plan: Mark N/a If Not Applicable)

    Uploaded by

    Virginia Amber Lindahl
    50 views13 pages
    This document contains a template for a nursing student to complete a clinical physical assessment and care plan. It includes sections for demographic data, chief complaint, medical history, physical assessment, medications, lab results, medical diagnoses, nursing diagnoses, and a nursing care plan. The nursing care plan requires the student to prioritize 3 nursing diagnoses, include expected outcomes, 3 interventions for each diagnosis with rationales, and an evaluation section. The document provides a grading rubric to evaluate students' completion of the required sections.

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    May 22

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    This document contains a template for a nursing student to complete a clinical physical assessment and care plan. It includes sections for demographic data, chief complaint, medical history, physical assessment, medications, lab results, medical diagnoses, nursing diagnoses, and a nursing care plan. The nursing care plan requires the student to prioritize 3 nursing diagnoses, include expected outcomes, 3 interventions for each diagnosis with rationales, and an evaluation section. The document provides a grading rubric to evaluate students' completion of the required sections.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    50 views13 pages

    RN Program Clinical Physical Assessment and Care Plan: Mark N/a If Not Applicable)

    Uploaded by

    Virginia Amber Lindahl
    This document contains a template for a nursing student to complete a clinical physical assessment and care plan. It includes sections for demographic data, chief complaint, medical history, physical assessment, medications, lab results, medical diagnoses, nursing diagnoses, and a nursing care plan. The nursing care plan requires the student to prioritize 3 nursing diagnoses, include expected outcomes, 3 interventions for each diagnosis with rationales, and an evaluation section. The document provides a grading rubric to evaluate students' completion of the required sections.

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    RN PROGRAM

    CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN

    STUDENT NAME: DATE:

    PATIENT INITIALS: ALLERGIES:

    AGE: LMP: (mark n/a if not applicable)

    PAIN: GRAVIDA: PARA: AB:


    (Is client experiencing any pain?)
    HEIGHT: PERCENTILE:

    WEIGHT: PERCENTILE:

    HEAD CIRC: N/A RELIGION:

    CHIEF COMPLAINT:

    HISTORY OF PRESENT ILLNESS

    PAST MEDICAL HISTORY

    CURRENT ORDERS

    DIET:

    ACTIVITY:
    TREATMENTS:

    DEVELOPMENTAL ASSESSMENT
    PIAGET’S STAGE:
    EVIDENCE:

    ERIKSON’S STAGE:
    EVIDENCE:

    PHYSICAL ASSESSMENT
    (Complete head to toe assessment. WNL is not accepted. Please be specific.)
    Neurologic:

    Respiratory:
    (Vitals Here)

    Cardiovascul
    ar:
    HR
    BP

    Gastrointest
    inal:

    Genitourinar
    y:

    Musculoskel
    etal:

    Integument
    ary:

    Psychosocial
    :

    Nutritional:

    MEDICATIONS
    Please include trade & generic name, dosage, action, reason your
    patient is receiving this medication, major side effects, and nursing
    implications.

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Patient/Family
    Generic PTs education
    Name Weight

    Dose Safe Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic Patient/Family
    Name PTs Weight Education

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose Safe dose?

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic , fever
    Name PTs Weight

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight
    Dose

    Route

    Trade Drug Action Is Dose Adverse Nursing


    Name Appropriat Reactions Implications
    e?
    Generic
    Name PTs Weight

    Dose

    Route

    LAB DATA & DIAGNOSTIC EVALUATION


    Include date

    LAB Ordered Client Normal Values Indication for Diseases / Illness


    Values
    .

    LAB Ordered Client Normal Values Indication for Diseases / Illness


    Values Why is the lab drawn?
    MEDICAL DIAGNOSIS

    MEDICAL DIAGNOSIS TEXTBOOK CLINICAL CLIENT’S ACTUAL CLINICAL


    PICTURE PICTURE
    Definition, Signs, and What Signs and Symptoms your patient
    Symptoms that should be actually exhibited
    seen
    PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS
    List all nursing diagnosis relevant to patient condition & based on assessment

    1.

    2.

    3.

    4.

    5.
    NURSING CARE PLAN

    Student Name: ____________ Date: ____________________ Class: ______

    Patient Initials: _______________


    A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest
    priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least
    one/ “expected outcome” measurable goal per nursing diagnosis stated in terms of client achievement - “the client will…”). List at least 3
    specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work
    toward that goal.

    NURSING EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION


    DIAGNOSIS (Measurable Goal) (What do you plan to do?) (Why are you doing
    (NANDA
    this?)
    APPROVED)
    NURSING EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION
    DIAGNOSIS
    NURSING EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION
    DIAGNOSIS
    References
    (APA format)
    Care Plan Grading Matrix

    Section Score Possible Points

    Demographic Data
    Name (student/pt initials), Date, Age, Pain score, Growth
    Measurements, CC, HPI, PMH, Current Orders, Developmental
    Assessment 10

    Physical Assessment 25
    Medication 10
    Lab & Diagnostic Evaluation 5
    Medical Diagnosis 5
    List of Prioritized Nursing Diagnosis One-part statements
    5

    Nursing Care Plan


    (Dx statements 3 part statements– minimum of 3, Goals –
    short & long term, Interventions – minimum of 3, Rationales – 1
    for each intervention, Evaluation) 30

    Citations, References & APA format 10

    Total 100%

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