STUDENT CARE PLAN
Student:
Patient/Client Initials:
Dates Cared for:
Date of Admission:
Medical Diagnosis:
Surgery (if any) and Date:
Marital Status:
Date:
M/F:
Rm. #:
Physician:
Pertinent Past History:
Health Insurance:
Pathophysiology of admitting diagnosis (diagnoses): (4 points)
Revised 5/99
Pathophysiology Reference Source(s):
Nursing Assessment Criteria - (2 points)
From the pathophysiology textbook or components of Medical-Surgical
text.
SUBJECTIVE:
OBJECTIVE:
PSYCHOSOCIAL:
RISK FACTORS:
Ref:
For acquiring the disease or condition. (May be found under etiology).
GORDON'S FUNCTIONAL HEALTH PATTERNS
STUDENT ASSESSMENT GUIDE (22 points)
#1
HEALTH MAINTENANCE MGMT.
Admit Date
SUBJECTIVE
OBJECTIVE
SUBJECTIVE
OBJECTIVE
Medical Diagnosis
Pertinent medical history
Pertinent psychosocial history
Insurance
Age
Allergies-Food and medicines
Erikson's Developmental Level
Tendency toward which pole
Perception of health status
Immunization status
Risk behaviors
Discharge needs
Medications prior to admission
#2
NUTRITION/METABOLIC
Diet
Recent intake (% of meals)
Food preferences
Abdomen
Bowel sounds
Nausea
NG Tube
IV Fluids
Intake/Output (no. of hours)
Temperature
Edema
Height, Weight
Body Mass Index
#3
ELIMINATION
Bladder
SUBJECTIVE
OBJECTIVE
Bowel patterns
Last BM
Skin
Braden scale score
#4
ACTIVITY/EXERCISE
Respiratory - Rate
Character of respirations
SUBJECTIVE
OBJECTIVE
Color
Breath sounds
SpO2
Cardiac
Apical pulse (rate, rhythm, sounds)
Peripheral pulses
Capillary refill time
Blood pressure
Homan's sign
ROM
Mobility (describe extent)
Assistive equipment
ADL performance
Leisure and recreation
#5
COGNITIVE/PERCEPTUAL
Pain (scale, characteristics)
SUBJECTIVE
OBJECTIVE
SUBJECTIVE
OBJECTIVE
Glasgow score
Sensory aids
Level of consciousness
Circulation, Motion, Sensation (CMS)
#6
SLEEP/REST
Pattern of Sleep
Quality/Quantity
#7
SELF-PERCEPTION/SELF-ESTEEM
Describes attitudes about self
and perception of abilities.
SUBJECTIVE
OBJECTIVE
SUBJECTIVE
OBJECTIVE
Attitudes about self
Impact of illness on self
Desire to change self
Nervous or relaxed: rate 1-5
Perceived powerlessness
Body posture
Eye contact
Assertive or passive: rate 1-5
Nonverbal cues to altered self-esteem
Facial expressions
#8
ROLE/RELATIONSHIP
Occupation
Recent change in Role
Comfort with Change
Marital Status
Family structure
#9
SEXUALITY
Menstrual history: children
SUBJECTIVE
OBJECTIVE
SUBJECTIVE
OBJECTIVE
Self-breast/testicular exams
Impact of illness on sexuality
Birth control
#10
COPING/STRESS
Expression of stress
Stressors
Usual coping mechanisms
Support systems
Family support
Community resources
#11
VALUE/BELIEF
Religious Preference
Spirituality
Cultural beliefs and practics
Practice of values/beliefs
Advanced directives
DNR
SUBJECTIVE
OBJECTIVE
STUDENT CARE PLAN
Laboratory Diagnostic Studies (2 points) - Relevant at this time:
DATE
TEST
NORMAL VALUE
PATIENT/CLIENT VALUE
REASON FOR TEST, SIGNIFICANCE OF ABNORMAL RESULTS FOR THIS PATIENT
Reference:
Radiological Diagnostic Studies - Relevant at this time.
DATE
Reference:
TEST
FINDINGS, SIGNIFICANCE FOR THIS PATIENT
MEDICATION WORKSHEET - (5 POINTS)
CLASSIFICATION
MEDICATION
USUAL
DOSAGE
ROUTE
MECHANISM OF ACTION
DRUG INTERACTIONS
TOXIC/SIDE EFFECTS
NURSING INTERVENTIONS
Current medical orders that form the basis for collaborative care: (1 point)
ARENA ASSESSMENT - (3 points)
How does each arena contribute to physical and psychosocial-spiritual well-being?
A.
Agency
a.
Physical
b.
B.
Family
a.
Physical
b.
C.
Psychosocial-spiritual
Psychosocial-spiritual
Community
a.
Physical
b.
Psychosocial-spiritual
STUDENT CARE PLAN WORKSHEET – (6 points)
STRENGTHS
WEAKNESSES
PRIORITIZE THREE AREAS OF CARE
RATIONALE FOR
Prioritize for Care
AND STATE EACH PROBLEM AS A
PRIORITIZATION OF PROBLEMS
Using Maslow’s Hierarchy of
NANDA DIAGNOSIS
DISCHARGE GOALS
Needs
1.
2.
_________________________________________
TEACHING NEEDS
_________________________________________
3.
Student Name:
2
p
NURSING DIAGNOSIS
DEFINITION:
Patient’s Medical Diagnosis:
DEFINING
CHARACTERISTICS:
o
i
n
RELATED
FACTORS:
t
STUDENT
INSTRUCTIONS:
s
A
S
S
E
S
S
M
E
N
T
D
I
A
G
N
O
S
I
S
In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
Gordon’s Functional health Pattern.
Subjective Data Entry (1 point)
Time Out!
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
PATIENT
Nursing Diagnosis (specify)
DIAGNOSTIC Related to
STATEMENT:
(2 points)
Objective Data Entry (1 point)
DESIRED OUTCOME: (2 points)
A. INTERVENTION
(2 points)
B. RATIONALE (reference) (2 points)
D.
Sample documentation or charting of nursing care and patient response. (2 points)
E.
Was the desired outcome achieved? (1 point)
C. EVALUATION (2 points)
Student Name:
2
p
NURSING DIAGNOSIS
DEFINITION:
Patient’s Medical Diagnosis:
DEFINING
CHARACTERISTICS:
o
i
n
RELATED
FACTORS:
t
STUDENT
INSTRUCTIONS:
s
A
S
S
E
S
S
M
E
N
T
D
I
A
G
N
O
S
I
S
In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
Gordon’s Functional health Pattern.
Subjective Data Entry (1 point)
Time Out!
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
PATIENT
Nursing Diagnosis (specify)
DIAGNOSTIC Related to
STATEMENT:
(2 points)
Objective Data Entry (1 point)
DESIRED OUTCOME: (2 points) .
A. INTERVENTION
(2 points)
B. RATIONALE (reference) (2 points)
D.
Sample documentation or charting of nursing care and patient response. (2 points)
E.
Was the desired outcome achieved? (1 point)
C. EVALUATION (2 points)
Student Name:
2
p
NURSING DIAGNOSIS
DEFINITION:
Patient’s Medical Diagnosis:
DEFINING
CHARACTERISTICS:
o
i
n
RELATED
FACTORS:
t
STUDENT
INSTRUCTIONS:
s
A
S
S
E
S
S
M
E
N
T
D
I
A
G
N
O
S
I
S
In the space below enter the subjective and objective data gathered during your patient assessment and include the appropriate
Gordon’s Functional health Pattern.
Subjective Data Entry (1 point)
Time Out!
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and
related factors associated with the nursing diagnosis and see how your patient data matches. Do you have an accurate match or is additional data
required or does another nursing diagnosis need to be investigated?
PATIENT
Nursing Diagnosis (specify)
DIAGNOSTIC Related to
STATEMENT:
(2 points)
Objective Data Entry (1 point)
DESIRED OUTCOME: (2 points) example sentence to show the use of underlining.
A. INTERVENTION
(2 points)
B. RATIONALE (reference) (2 points)
D.
Sample documentation or charting of nursing care and patient response. (2 points)
E.
Was the desired outcome achieved? (1 point)
C. EVALUATION (2 points)
REFERENCE PAGE