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Course: NURS 101L
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L
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Student
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Date
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Instructor
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Course
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Patient Initial
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Unit/ Room#
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DOB
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Code Status
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Height/Weight
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Allergies
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Temp (C/F Site)
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Pulse (Site)
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Respiration
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Pulse Ox (O2 Sat)
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Blood Pressure
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Pain Scale 1-10
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History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations
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Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
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Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
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Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations
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Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations
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Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx)
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations
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Signs and
Symptoms
As evidenced by
Related to
Contributing
Factors
Diagnostic
Label
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Priority Nursing Diagnosis
(at least 2)
Written in three part statement
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Planning
(outcome/goal)
Measureable goal during your shift
(at least 1 per Nursing diagnosis)
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Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal)
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Rationale Each must be
supported with Evidence Based Citations
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Evaluation
Goal Met, Partially Met,
or Not Met
& Explanation
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MEDICATION LIST
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Medications (with APA citations
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Class/Purpose
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Route
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Frequency
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Dose (& range)
If out of range, why?
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Mechanism of action
Onset of action
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Common side effects
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Nursing considerations
specific to this patient
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Revision Date: Month, Year (i.e. February, 2010) Page 1
Page 1 of 3
Patient Introduction
Location: Orthopedic unit 1555
SBAR report from day shift nurse:
Situation: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery tomorrow.
Background: Mrs. Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently Mrs. Jacobson has been having dizzy spells.
Assessment: Mrs. Jacobson’s vital signs are stable. Her pain is under control with morphine every 4 hours, and I medicated her at 1400. Her pain level was 2 after the morphine. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented.
Recommendation: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.
Diseases and Conditions
1. Expert Clinical Content from Lippincott Advisor
2.
Hip fracture
Hip fracture
3.
Osteoporosis
Osteoporosis
Pharmacology
1. Expert Clinical Content from Lippincott Advisor
2.
morphine sulfate-naltrexone hydrochloride
morphine sulfate-naltrexone hydrochloride
3.
raloxifene hydrochloride
raloxifene hydrochloride
Procedures
1. Expert Clinical Content from Lippincott Procedures
2.
Passive range of motion exercises
Passive range of motion exercises
3.
Antiembolism stocking application, knee-length
Antiembolism stocking application, knee-length
4.
Fall management
Fall management
5.
Fall prevention
Fall prevention
6.
Body mechanics
Body mechanics
