2Patient Care PlanStudent Name Ana G. Mendez University Class Name Rachel Quintana, RN, BSN Date

2

Patient Care Plan

Student Name

Ana G. Mendez University

Class Name

Rachel Quintana, RN, BSN

Date

Patient Demographics

Patient Initials:

Age:

Sex:

Culture/Ethnicity:

Allergies:

Weight:

Height:

BMI:

Code Status:

Language:

Occupation:

Marital Status:

Current work status:

Highest grade completed:

Blood Pressure:

Heart Rate:

Respiration Rate:

Temperature:

Oxygen Saturation:

Pain:

(include scale used)

Health History

History of present illness:

Past Medical History:

Surgical History:

Social History:

Diagnostic procedures:

Surgical procedures:

Labs:

Diet with rationale:

Activity order:

Limitations/prosthetic devices:

Current medications:

Nursing Diagnoses

Nursing Diagnosis 1

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Diagnosis 2

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Diagnosis 2

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Interventions

Nursing Diagnosis 1

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Nursing Diagnosis 2

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Nursing Diagnosis 3

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Evaluation

Explain if and how the interventions worked for the patient.

Discharge Planning

Write a discharge plan for this patient.

Pathophysiology

Write a brief summary regarding this patient’s main diagnosis as if you were explaining it to the patient.

References

References should be no older than 5 years and in APA 7 format.

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