Care Plan 2021

University of Central Oklahoma
Adult Med-Surg Nursing I

Nursing Care Plan Assignment
Name: Date of Clinical: Care Plan:
Medical History: Code Status: FULL DNR DNI
Admission Medical Past Medical & Surgical Current Medical Diagnosis

Diagnosis [DATE] History [Hospital Day]
History of Present Illness: What brought the patient to the hospital? Summarize the patient’s
medical problems or progress since admission to the hospital.
Pathophysiology of the Current Medical Diagnosis: Use your nursing textbook to describe
the pathophysiology and manifestations of the patient’s MAJOR MEDICAL DIAGNOSES.
Do any of the patient’s co-morbidities impact this medical diagnosis?
Demographic Data/ Social History: Include your patient’s age, gender, height, weight, marital
status, social support, and cultural or religious considerations. Also include any other
circumstances that impacts the plan of care such as homelessness.
1
Lab & Diagnostic Tests: List the value on the day of clinical. For Abnormal Labs 1) state
if value is improving or worsening since admission; 2) describe what the abnormal value
indicates (what is causing the abnormal value for your patient?} and 3) what nursing
interventions would you implement based on the abnormal value?
Diagnostic Tests (Such Date Findings and relevance for patient

as X-Rays, CT Scans, etc.)
Complete Blood Count Normal Value Clinical Abnormal Values (see guidelines above)
(CBC) Range
WBC
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Hemoglobin
Hematocrit
Platelets
Complete Metabolic
Panel (CMP)
Sodium
Potassium
CO2
Chloride
BUN
Creatinine
Glucose
Albumin
Total Protein
Calcium
Magnesium
ALT
ALP/SGPT
AST/SGOT
Bilirubin
Other: Also include any lab values pertinent to patient’s condition, for example the patient
with heart disease include results of Troponin, CPK-MB, or BNP.
2
Medications: List all the medications the patient is prescribed and add new medications to
the master list.
Patient’s Allergies:
Scheduled Medications
Commercial [Generic] Dose Route Scheduled Did You
Name Time(s) of give it?
Administration
PRN Medications
Commercial [Generic] Dose Route Scheduled Did You
Name Time(s) of give it?
Administration
3
List of Nursing Diagnosis
 First, analyze your assessment data and highlight all abnormal assessment findings. Be
sure to include all sources of assessment data such as medical history & social history,
lab & diagnostic tests, abnormal lab values, and physical assessment findings.
 Formulate a comprehensive nursing diagnosis list based on your analysis. For each
nursing diagnosis, list the assessment findings that supports the nursing diagnosis.
All abnormal assessment findings should be linked to a nursing diagnosis.
Nursing Diagnosis Supporting Abnormal Assessment Findings
VII. Priority Setting Rank the top 3 priority nursing diagnosis for your patient. Use A, B,
C’s and Maslow’s Hierarchy to provide rationale for your choices.
Nursing Diagnosis Rationale

#1.
#2.
#3.
Were your priorities different than what you had determined in preplanning? Explain
4
DAY OF CLINICAL
Assessment Documentation of Findings

Psychological
 General Appearance & Behaviors
Neurological
• LOC & Orientation
• Pupils
• Speech and Verbal Response
• Motor function
• Deficits
Cardiovascular and Peripheral Vascular
• Heart Sounds (S1-S2) / Rhythm
• Pulses (on scale 0-4+ or doppler,
radial, DP, PT bilaterally)
• Cap Refill
• Lower extremity color/
temperature/ edema
Respiratory
• Rate/ Pattern / Effort
• Lung Sounds
• Cough/Sputum
Abdominal
• Inspection/ Palpation /
Auscultation of Bowel Sounds
• Date of Last Bowel Movement
• Diet & Nutritional Intake
Genitourinary
• Urine (color, clarity, frequency,
amount)
• Altered Urinary Method
• Dialysis
Musculoskeletal
• Gait
• Joints & Muscle
• Ability to Perform
ADL’s
Integumentary
• Skin Color / Temperature
• IV Site Inspection
• Wounds/Incisions/Lacerations
5
Fluid Volume Status
• 24 hr. I&O
• Daily Weight (amt gained or lost
since admit weight)
• Skin Turgor & Mucous
Membranes
• Edema (1-4+, dependent, trace,
tight, location)
Lines /Drains/ Other treatments

 SCDS, Drains, Suction, Chest
Tubes, Wound Vac, LVADs, or
Tracheotomy
Vital Signs, FSBS, Pain

 B/P, Pulse, Resp, Temp, O2 Sat
 FSBS
 Pain: Intensity, Location, Time of
Onset, Duration, Aggravating &
Relieving Factors, Effectiveness of
Relief Measures
Nursing Care Activities and Documentation
 Describe the nursing care activities that you performed for patient during the clinical day
such as assisting with mobility, activities of daily living, therapeutic communication,
passing medications (include routes administered), starting an IV, inserting a foley
catheter.
 Provide one sample documentation for a nursing activity you performed.
Nursing Diagnoses (2)

 During Clinical – implement the planned interventions. After clinical, evaluate the
effectiveness of the interventions. Be sure to state if the expected outcomes were met or
not.
 Add new NDx to the master list.
6
Self-reflection

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University of Central Oklahoma

Adult Med-Surg Nursing I

Name: Date of Clinical: Care Plan:

Medical History: Code Status: FULL DNR DNI

Admission Medical Past Medical & Surgical Current Medical Diagnosis

Diagnostic Tests (Such Date Findings and relevance for patient

Nursing Diagnosis Supporting Abnormal Assessment Findings

Nursing Diagnosis Rationale

Assessment Documentation of Findings

Lines /Drains/ Other treatments

Vital Signs, FSBS, Pain

Nursing Care Activities and Documentation

Nursing Diagnoses (2)

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