NURSING 239 CAREPLAN
CARE PLAN WORKSHEET
Student Name:
Date cared for pt:
LIST MEDICAL DIAGNOSES & PROBLEMS:
Pt.’s Initials:
SBAR
Surgery
Medication
Diet/Activity
Code Status
Social History
IV
Medical History
Age:
LIST POSSIBLE NURSING DIAGNOSES:
Diagnosis
Allergies
Sex:
weight:
NURSING 239 CAREPLAN
(LAB VALUES, diagnostics, VS, PHYSICAL SYSTEMS,
A
psychosocial, spiritual, ethical)
S
SUBJECTIVE DATA ENTRY
OBJECTIVE DATA ENTRY
Date
Temp
P
R
B/P
O2SAT
Date
WBC
RBC
Hgb
Hct
Plt Cnt
S
E
S
OBJECTIVE DATA ENTRY
S
M
E
Date
N
T
Intake
Output
Balance
Na
K
Cl
BUN Creatinine GFR
Glucose
Ca
NURSING 239 CAREPLAN
NURSING
DIAGNOSIS:
DESIRED
OUTCOME:
I
N
T
E
R
V
E
N
T
I
O
N
S
INTERVENTIONS: Assessments, nursing and medical treatments, Teaching
NURSING 239 CAREPLAN
INTERVENTIONS
Outcome Achieved
NURSING 239 CAREPLAN