SOUTHERN UNIVERSITY

SCHOOL OF NURSING
NURSING CARE PLAN Level III
STUDENT NAME _______________________________________________________________DATE__________________________________
COURSE TITLE & NUMBER ____________________________________________________________________________________________
CLIENT INFORMATION
Clients initials _________________Age _____________ Sex _____________ Religion ______________________________________________
Socio-Cultural Background _______________________________________________________________________________________________
Growth & Development Stage (Erikson, Piaget, or Kohlberg) __________________________________________________________________
MEDICAL DIAGNOSIS DATA
Primary Diagnosis ______________________________________________________________________________________________________
Secondary Diagnosis ____________________________________________________________________________________________________
Date of Surgery ___________________________ Admission Date ___________________________Admission Weight (kg) ________________
Type of Surgery ________________________________________________________________________________________________________
Clinical area of health care agency _________________________________________________________________________________________
Reason for admission ____________________________________________________________________________________________________
Assmt (4)
______________
WATSONS CARATIVE FACTORS _____________________________________
Nursing Diagnosis (4)
______________
Planning (5)
______________
______________________________________________________________________
Intervention (Includes meds)(5)
______________
Rationale ( 3)
______________
COMMUNITY RESOURCE_____________________________________________
Evaluation (7)
______________
APA/grammar (2)
______________
Total ______/30 x 100 =
____________%

Pertinent Diagnostic Procedures and Interpretation (Please Date Labs)

Diagnostic
Procedure

CBC
RBC
WBC
Hgb
Hct
MCV
MCHC
RDW
Platelets
MPV
DIFF
Neutrophils%
Lym %
Mono %
Eosino %
Baso %
Neut A
Lym A
Mono A
Eos A
Basos A
CHEMISTRY
Sodium (Na)
Potassium (K)
Chloride (Cl)
CO2
Glucose
BUN
Creatinine
Calcium

Pre and Post

Procedure
Nursing Implications

Normal
Findings/Values
for this Procedure

Clients Results for

this Diagnostic
Procedure (Admit)
Date

Date:
Client's Results
for this
Diagnostic
Procedure
(Recent)
DATE:

DATE:

DATE:

Interpretation of These Findings

as Applicable to this Client
& Explain trends

Diagnostic
Procedures

Pre and Post

Procedure
Nursing Implications

Normal
Findings/Values
for this Procedure

Bleeding Time

Clients Results for

this Diagnostic
Procedure (Admit)

Client's Results
for this
Diagnostic
Procedure
(Most recent
values)

DATE:

DATE:

DATE:

DATE:

DATE:

DATE:

PT
PTT
INR
ARTERIAL
BLOOD
GASES
PH
PCO2
PO2
HCO3
SaO2
CULTURE &
SENSITIVITY
SOURCE
BODY SITE
REPORT

Interpretation of These Findings

as Applicable to this Client
& Explain trends

Diagnostic
Procedures

URINALYSIS
Color
Clarity
SpGr
pH Ur
Prot Ur
Glucose Ur
Ketone
Hgb Ur
Bili urine
Urobil
Leukocyte
esterase
Nitrate
WBC Ur
RBC urine
Epith Ur
DIAGNOSTIC
STUDIES

Normal
Findings/Values
for this Procedure

Clients Results for

this Diagnostic
Procedure (Admit)

Client's Results
for this
Diagnostic
Procedure
(Most recent
value)

DATE

DATE:

DATE

DATE:

Interpretation of These Findings

as Applicable to this Client
& Explain trends

Diagnostic
Procedures

OTHER TEST

Pre and Post

Procedure
Nursing Implications

Normal
Findings/Values
for this Procedure

Clients Results for

this Diagnostic
Procedure (Admit)

DATE

Client's Results
for this
Diagnostic
Procedure
(Most recent
values)
DATE:

NURSING CARE PLAN ASSESSMENT

Interpretation of These Findings

as Applicable to this Client
& Explain trends

UNIVERSAL REQUISITES

DEVELOPMENTAL
REQUISITES

HEALTH DEVIATIONS
PATHOLOGY & SIGNS &
SYMPTOMS

NURSING CARE PLAN

SELF-CARE DEFICITS

NURSING DIAGNOSIS

PLAN

IMPLEMENTATION

EVALUATION

NANDA LIST

Nursing Outcomes/Goals
Classification (NOC)
SHORT-TERM/LONG-TERM

Nursing Interventions
Classifications (NIC) and
Rationales (cite source)

OUTCOMES/REVISIONS

Instructor Feedback________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

MEDICATION FORM

DRUG
Clients weight
(kg)___________
Generic name:
Trade name:
Classification:
Recommended dose:
Clients dose:

Generic name:
Trade name:
Classification:
Recommended dose:
Clients dose:

CALCULATION

ACTION
Why is patient receiving
medication?

SIDE EFFECTS/
CONTRAINDICATIONS

NURSING
IMPLICATIONS/
PATIENT TEACHIING