Client Initials

Culture/Ethnicity

Support system:

Unit 2 Room/Bed

Religion

Age Sex

Language

Weight Height

Marital status N/A

Current medical diagnosis

Occupation:

Siblings

Health insurance :

Name of significant other/primary caregiver

Current work status N/A

Highest grade completed

Genogram: See attachment

Diagnostic procedures:

Surgical procedures:

Pathophysiology/psychopathology (List reference)

Psychopathology:

DEVELOPMENTAL STAGE/THEORIST

Vital signs/Frequency

_________________________________

Allergies/Side effects

_________________________________

Diet with rationale

_________________________________

Activity order

_________________________________

Limitations/prosthetic devices

_________________________________

_________________________________

Theorist:

BRIEF HEALTH HISTORY

PERTINENT LABORATORY DATA Lab Test #1

Rationale of abnormal results

PERTINENT LABORATORY DATA Lab Test #2

Rationale of abnormal results

_________________________

_________________________

_________________________

__

___________________________

___________________________

_________________________

PERTINENT LABORATORY DATA Lab Test #3

Results

___________________________

Rationale of abnormal results

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

PERTINENT LABORATORY DATA Lab Test #4

___________________________

Results_____________________

___________________________

___________________________

___________________________

___________________________

Rationale of abnormal results

___________________________

___________________________

___________________________

___________________________

___________________________

INTRAVENOUS SOLUTION #1

Type

CC/HR gtts/min

Additives:

Rationale for solution –

INTRAVENOUS SOLUTION #2

MEDICATION NAME

TRADE/GENERIC

DOSAGE ORDERED

TIMES ADMINISTERED

DOSE ROUTE

RATIONALE FOR ADMINISTERING

THERAPEUTIC RANGE FOR AGE/WEIGHT

NURSING IMPLICATIONS

NURSING DIAGNOSES

LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY)

DESCRIBE RATIONALE FOR PRIORITY ORDER

UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE

(Reference)

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

Include subjective and objective components.

Assess physiological, psychosocial, developmental, cultural and spiritual dimensions.

• Subjective

Document client's exact words relevant to the diagnosis.

"I'm not hungry"

• Objective

Document data that is measurable, specific, and relevant to the nursing diagnosis.

"Weight = 48 Kg"

"Lack of subcutaneous fat"

Use a NANDA diagnosis which has three (3) parts:

•Part I: NANDA statement of nursing problem

" Alternation in nutrition: Less than body requirements"

•Part 2: relating to a nursing etiology:

" relating to inadequate nutritional intake"

•Part 3: manifested by the assessed signs and symptoms:

" manifested by low body weight and emaciation."

State the overall plan as client centered, e.g.,:

•" The client will…"

Relate the plan to the nursing diagnosis:

•." have adequate nutritional intake"

Indicate a measurable outcome criteria by including time frame/amount/range:

•" as evidenced by…"

1) the ability to create a balanced meal plan by day (7).

2) gaining 1-2 lbs/wk until FDA recommended weight is achieved.

(3) etc.

Make the interventions nurse centered.

Indicate what the nurse will do to assist the client in achieving the outcome criteria, e.g.,

• The nurse will…"

State frequency/time

/amount so any nurse can carry out the plan:

1) Document all food intake for 3 days.

2) Determine and make available client's favorite foods by day 2.

3) etc.

State the principle or scientific rationale for the nursing intervention(s).

Include the reference for the rationale.

Look at the outcome criteria.

State whether the client achieved the outcome criteria, e.g.,

" The client gained 2 lbs within the past 7 days…"

NOTE:

If the outcome criteria was not achieved or only partially achieved, the nurse needs to go back to the beginning, e.g., the "assessment" and make revisions or changes as necessary.

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION