care plan template-lpn (revised)

Student Name: ________________________ Date : ________________________

Instructor: ________________________ Care Plan No: __________________

Clinical Site: ________________________ Clinical Rotation: _______________

Patient Profile

Initials: Age: Sex: Race:

Admitting Diagnosis:

Medical Diagnosis:

Data Collection

Subjective Data (Patient Statements)

Note: If patient is non-verbal or unable to communicate in English be sure to document objective and observable data such as: body language, facial expressions, gestures, body positioning, ect.

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Objective Data: (Attach clinical assessment form and provide a summary of each system)System Summary

Psychosocial:

Neuorosensory:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Skin:

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Nursing Diagnosis

A minimum of 3 NANDA nursing diagnosis should be presented. The nursing diagnosis should follow the PES format:

P – (Problem) – nursing diagnosis/label E – (Etiology) – related to, or contributor to the problem S – (Symptoms) – defining characteristics (as evidenced by)

Example: NANDA Diagnosis: Decreased cardiac output related to altered myocardial contractility as evidenced by shortness of breath with mild exertion and crackles bilaterally.

Nursing Diagnosis 1:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis 2:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis 3:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis 4:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Planning:

(Identify 3 patient specific goals, nursing interventions, the rationale for the intervention and the outcome evaluation which will determine if the patient goal has been met)

Goal Intervention Rationale Outcome Evaluation

List reference used for data and cite page number (s):

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Student Documentation

Using the PIE method, document a note that would be included in the patient’s chart based on one or more of the following factors:

◊ Medical Condition ◊ Nutritional Needs ◊ Teaching Needs

◊ Psychosocial Needs ◊ Spiritual Needs ◊ Cultural Needs/Implications

◊ Laboratory/Diagnostic Results ◊ Pharmacological Interventions

Example:

P = Problem (Based on Subjective or Objective Data)I = InterventionE = Evaluation

P - Patient complaining of nausea and lack of appetite. Vomited 45 minutes after breakfast and refused lunch.I – Charge nurse alerted to the fact that the patient is nauseous and episode of vomiting. Physician called by primary RN and antiemetic ordered.E – Compazine given as ordered, 30 minutes before dinner. Patient able to eat 240 ml of chicken soup and drink 120 ml of sprite for dinner.

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P – _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I – _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

E – _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Laboratory Data

Date Test Patient Result Normal/Abnormal Normal Range

Test Description

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Medications

Drug/Class(Dose, Route &

Frequency)

Action Contraindications Side Effects Nursing Interventions

Patient Teaching

List reference used for data and cite page number (s):

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Clinical Instructor Grading Sheet

Care Plan Strengths Care Plan Weaknesses/Areas for Improvement Patient Assessment Subjective Data Objective Data Systems Summary NANDA Nursing Diagnosis Patient Planning PIE Documentation Laboratory Data Medications Writing Style Critical Thinking Skills

Other:

Patient Assessment Subjective Data Objective Data Systems Summary NANDA Nursing Diagnosis Patient Planning PIE Documentation Laboratory Data Medications Writing Style Critical Thinking Skills

Other:

Instructor Signature:________________________________________________ Date:__________________________________

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