A care plan on a patient with a cardiac, respiratory, gastrointestinal, or neurological primary diagnosis
CARE PLAN GUIDELINES
Use of appropriate sources and APA format (in-text citations and a reference page) are required for all care plans. No abbreviations will be accepted.
Completing a care plan on a patient with a cardiac, respiratory, gastrointestinal, or neurological primary diagnosis is strongly recommended.
Student Name: Date:
Patient Initials: Room #: Age: Admin. Date:
Sex: Height: Weight:
Ethnicity: Race: PrimaryDiagnosis:
Occupation (current or previous): SecondaryDiagnosis:
Allergies: Diet: Current SurgeryDate / Type (if applicable):
Fill out the above chart with the patient’s demographic and admission data.
History of Presenting Illness (Chief Compliant):
A narrative summary of the patent’s admission (i.e., admission date, presenting
signs and symptoms, reason for admission in the patient’s own words [i.e., “my stomach hurts”], and admitting medical and/or surgical diagnoses
Past Medical and Surgical History:
List your patients past medical and surgical history.
Diagnostic Testing (recently completed or to be complete):
Briefly describe any diagnostic test and discuss basic findings /
interpretations, if the test was already completed (i.e., Chest X-
ray, ultrasound, etc.)
Nursing Activities and Medical Equipment:
List nursing activities and medical equipment ordered for you patient and then
briefly discuss nursing care considerations for each [be sure to cite a source in APA format for nursing care considerations i.e., (Jones & Smith, 2012)].
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