Nursing Care Plan (Er)
Content
NURSING CARE PLAN
Patient Name: Medical Diagnosis: Attending Physician:
Age:
Sex:
Civil Status:
I.
Chief Complaint / Other complaints:
II.
Nursing History
III.
Pathophysiology and Explanation
IV.
Laboratory / Diagnostic Result, Interpretation and Nursing Implication
V. Brand Name Generic Name
Medications and Treatment Dosage / Frequency / Route Indication / Contraindication Side Effects / Adverse Reaction Nursing Responsibilities
VI.
Nursing Priorities
VII.
Nursing Care Plan
Assessment Subjective / Objective
Nursing Diagnosis
Short Term Goal
Long Term Goal
Intervention
Rationale
Evaluation / Expected Outcomes
Patient Name: Medical Diagnosis: Attending Physician:
Age:
Sex:
Civil Status:
I.
Chief Complaint / Other complaints:
II.
Nursing History
III.
Pathophysiology and Explanation
IV.
Laboratory / Diagnostic Result, Interpretation and Nursing Implication
V. Brand Name Generic Name
Medications and Treatment Dosage / Frequency / Route Indication / Contraindication Side Effects / Adverse Reaction Nursing Responsibilities
VI.
Nursing Priorities
VII.
Nursing Care Plan
Assessment Subjective / Objective
Nursing Diagnosis
Short Term Goal
Long Term Goal
Intervention
Rationale
Evaluation / Expected Outcomes
