Nanda Care Plan Template - PDF

							                                        Student Care Plan
I. Client Initials___________________                       Student ________________________

Client Age_____________________                             Date___________________________

               Diagnosis                       Definition   Etiology, Sign, Symptoms
II.                         Allergies_______________________
      Drugs, Dose & Route                Classification        Rationale (why is your client taking this drug?)
III. Diet (Type)                                                    Rationale
     Intravenous [IV] (Type)                                        Rationale


IV. Treatments (List all treatments; refer to chart, medication sheets, Kardex & treatment nurse.)

                Treatments                  Frequency/Duration                      Rationale (scientific reasoning)




            Diagnostic Studies                  Date / Results                   Importance of results for nursing care
                  X-Ray




                Ultrasound




                    EKG
V. LAB (List additional labs values that are significant for your client [consider diagnoses and medications])

                  Text                     Admin (      )    Current (    )    Normal What has happened to change these values (consider
                                           Values / Date     Values / Date     Values meds and diagnosis)?
                   WBC
                 Hgb/Hct
                 Platelets
                 Glucose
                   BUN
                Creatinine
                    Na
                     K
                    Cl
                   CO2
VI. Nursing Assessment (chart your head to toe assessment: VS, all body systems, dressing tubes, foley caths, tube feedings, etc.)
NEURO -

CV -

PULM -

GI -

GU -

SKIN -

MS -


VII. Care Plan (Each problem should be carried through from the left to the right with all areas being addressed.)
     Problems/Nursing DX                 Goals                   Interventions                    Rationale                          Evaluation

Refer to assessment. List       Short term goals need to be     List all interventions    The reason that you do each   State specific data that indicates
actual or potential problems.   measurable. Given specific      for problems identified   intervention (scientific      whether the goal was met or not.
Be sure to use NANDA            time frame in which goal will   separately. Refer to      reasoning)
nursing diagnoses.              be achieved.                    texts.
VII. Care Plan (Continued)

   Problems/Nursing DX       Goals   Interventions   Rationale   Evaluation
VII. Care Plan (Continued)

   Problems/Nursing DX       Goals   Interventions   Rationale   Evaluation