Scribd Logo
Upload

Welcome to Scribd!

  • 90 views

    Nursing Care Plan: Clinical Portrait Pertinent Data

    Uploaded by

    yuri ranchalouv
    The nursing care plan document contains sections for assessing a patient's clinical portrait including medical history, vital signs, and lab results. It also includes a nursing diagnosis section explaining the problem, goal and expected outcomes, nursing actions and orders to address the problem, and an evaluation section to assess if the goal was met. The document provides a standardized format for nurses to comprehensively document a patient's status, plan of care, and progress.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nursing Care Plan: Clinical Portrait Pertinent Data

    Uploaded by

    yuri ranchalouv
    90 views3 pages
    The nursing care plan document contains sections for assessing a patient's clinical portrait including medical history, vital signs, and lab results. It also includes a nursing diagnosis section explaining the problem, goal and expected outcomes, nursing actions and orders to address the problem, and an evaluation section to assess if the goal was met. The document provides a standardized format for nurses to comprehensively document a patient's status, plan of care, and progress.

    Original Title

    APznzab5GeT1eE2vVF317MMLnatiRO_lFZ1yQONUsUmfMueOCE2NBpIX4DI5A4r4dxVYZWrLTcHVcTKSuaapRYFZO77-LS8bPC7Z9NCnNo3VxucQLWIJw5Bt4q-qBt62gQRStvGG3hjHvZOLcHVAqYMkUs_jZ49jrZEMSHClzXEPQa9DvUeRZWPYJ3rai1buSeYZOmpQXraD65y_b

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The nursing care plan document contains sections for assessing a patient's clinical portrait including medical history, vital signs, and lab results. It also includes a nursing diagnosis section explaining the problem, goal and expected outcomes, nursing actions and orders to address the problem, and an evaluation section to assess if the goal was met. The document provides a standardized format for nurses to comprehensively document a patient's status, plan of care, and progress.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    90 views3 pages

    Nursing Care Plan: Clinical Portrait Pertinent Data

    Uploaded by

    yuri ranchalouv
    The nursing care plan document contains sections for assessing a patient's clinical portrait including medical history, vital signs, and lab results. It also includes a nursing diagnosis section explaining the problem, goal and expected outcomes, nursing actions and orders to address the problem, and an evaluation section to assess if the goal was met. The document provides a standardized format for nurses to comprehensively document a patient's status, plan of care, and progress.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3
    At a glance
    Powered by AI
    The document outlines the structure and components of a nursing care plan, including sections on clinical portrait, nursing diagnosis, goals and outcomes, and nursing actions and orders.

    A nursing care plan follows the nursing process and includes sections for assessment, planning, intervention and evaluation. It includes components such as the patient's history and vital signs, nursing diagnosis, goals and outcomes, and nursing actions and orders.

    The nursing diagnosis section includes the nursing diagnosis, scientific basis, goal and outcome criteria.

    University of Cebu – Banilad

    College of Nursing
    Cebu City

    NURSING CARE PLAN

    Patient’s Name : Hospital No. :


    Age : Room No. :
    Impression/Diagnosis: Physician :

    CLINICAL PORTRAIT PERTINENT DATA

    1. Assessment (general impression from head to toe) 1. History of present illness

    2. Chief complaints

    2. Significant findings
    3. Health history relevant to present illness

    3. Vital signs taken during the nurse’s first contact with the 4. Vital signs taken during admission
    patient

    5. Laboratory results regardless of findings


    RATIONALE
    NURSING
    NURSING SCIENTIFIC OF
    CUES GOAL & OUTCOME CRITERIA ACTIONS & EVALUATION
    DIAGNOSIS BASIS NURSING
    NURSING ORDERS
    ORDERS
    S– Format: Explains the Goal Nursing Actions
    existence of the  general outcome • general Explanations Filled out only
     Subjective data Problem r/t nursing diagnosis.  broad statement Nursing Orders why the nurse after care has
    Etiology Outcome Criteria • specific does such been given
     " “  specific functions in
     use
    Write the author  measurable Write in the sequence of detail, except Write the
    below the  attainable the nursing functions: medications following
    NANDA statement. 1. Independent because a statement
     " “, for the (Brunner  realistic
    &  time – bounded 2. Dependent separate drug accordingly:
    proble Suddarth, 2001) 3. Collaborative summary would
    as verbalized by …  2 – 3 outcome criteria for every
    m suffice. 1.Goal met:
    goal Follow the steps of the
    nursing process:
    Format: 1. Assessment
    O– 1. Subject 2. Planning 2.Goal partially met:
     Client 3. Intervention
     Objective data  Any body part of the
    client Example:
     Observations derived  Some attributes of the Independent 3.Goal not met:
    from: client A
    1. Nurse’s 5 senses 2. Verb P
    2. Laboratory results  What the client will do, I
    3. Diagnostic results learn, experience Dependent
    3. Conditions/modifiers A
     v/s of which must be  Explains the what, P
    related to the where, when, how I
    subjective data 4. Criteria of desired performance Collaborative
     Standard by which the A
    performance is P
    evaluated I
    NURSING RATIONALE
    NURSING SCIENTIFIC ACTIONS & OF
    CUES GOAL & OUTCOME CRITERIA EVALUATION
    DIAGNOSIS BASIS NURSING NURSING
    ORDERS ORDERS

    You might also like