SU_NSG6001_POC_TemplateNursing2.pdf

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    Running head: NAME OF CARE PLAN 1

    Title of Plan of Care

    Name

    South University Online

    Faculty Name

    NSG 6001

    Date

    NAME PLAN OF CARE 2

    **Please delete this statement and anything in italics prior to submission to shorten the length

    of your paper.

    Patient Initials ______

    Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

    Chief Compliant: (In patient’s exact words)

    History of Present Illness: (Analysis of current problems in chronologic order using symptom

    analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated

    symptoms and treatments tried]).

    PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major

    medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,

    obstetric and history sexual history).

    Significant Family History: (Includes family members and specific inheritable diseases).

    Social History: (Includes home living situation, marital history, cultural background, health

    habits, lifestyle/recreation, religious practices, educational background, occupational history,

    financial security and family history of violence).

    Review of Symptoms: (Review each body system – This section you should place POSITIVE for…

    information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;

    ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;

    Neurological:; Endocrine:; Hematologic:; Psychologic: .

    Objective Data:

    Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

    Physical Assessment Findings: (Includes full head to toe review)

    HEENT:

    Lymph Nodes:

    Carotids:

    Lungs:

    Heart:

    Abdomen:

    Genital/Pelvic:

    Rectum:

    Extremities/Pulses:

    Neurologic:

    Laboratory and Diagnostic Test Results: (Include result and interpretation.)

    Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of

    priority.)

    Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as

    education and counseling provided).

    NAME PLAN OF CARE 3

    References

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