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Nursing City Colleges of Chicago School of Nursing Nursing 210 Intermediate Medical-Surgical Nursing Major Clinical Plan of Care Student Name______

Nursing City Colleges of Chicago

School of Nursing

Nursing 210
Intermediate Medical-Surgical Nursing
Major Clinical Plan of Care

Student Name______

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Nursing City Colleges of Chicago

School of Nursing

Nursing 210
Intermediate Medical-Surgical Nursing
Major Clinical Plan of Care

Student Name_____________________________ Date____________

Patients initials Race: ____________________________ Age:

DOB: Gender:

Source of Information: _______________________________________

Marital Status:

Primary Medical Diagnosis________________________________________________________

Secondary Medical Diagnosis: ____________

Vital signs: T P R B/P SP02

Pain Score (1-10) Location ________________________________________

Allergies: Diet:_______________________________

Chief Complaint (CC) or Reason for Seeking Emergency Care

History of Present Illness or Problem (HPI):

Past Medical History (PMH)

Review of Systems (ROS)

General:

Skin:

Musculoskeletal:

Head and Neck:

Endocrine:

Females: Menses, Pregnancies, Breast

Males: Prostate:

Chest and Lungs:

Heart and blood vessels:

Hematologic:

Lymph Nodes:

Gastrointestinal:

Genitourinary:

Neurological:

Psychiatric/Mental Health:

Physcial Exam

General:

HEENT:

Neck:

Chest and Lungs:

Cardiovascular

Abdomen/gastrointestinal:

Genitourinary:

Rectal:

Musculoskeletal:

Lymphnodes

Skin:

Neurological:

Psychiatric/Mental Health:

Significant AND/OR abnormal Labs:

Interpretation:

Procedures, Surgeries or Treatments

Interpretations/Results:

IVF’s

1) IV solution ordered:

Rate ml/hr

Rationale for solution:

2) IV solution ordered:

Rate ml/hr

Rationale for solutions:

Drips

IV drip ordered:

Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.

Show calculations

Rationale for solution:

Show calculations

IV drip ordered:

Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.

Show calculations

Rationale for solution:

Show calculations

Rev 10/2021

Medications:

Brand & Generic Name

Classification:

Dosage/Route/Frequency:

Side Effects:

Nursing Considerations:

1

2

3

4

5

6

7

8

Nursing Diagnosis:

(NANDA)

Physical (1)

Planning/Outcome

Goal

Short Term:

Long Term:

Nursing Actions

(Interventions)

1.

2.

3.

4.

Rationales:

1.

2.

3.

4.

Evaluation:

Was the goal met, in progress or unmet?

Explain?

Nursing Di)agnosis:

(NANDA)

Physical (2)

Planning/Outcome

Goal

Short Term:

Long Term:

Nursing Actions

(Interventions)

1.

2.

3.

4.

Rationales:

1.

2.

3.

4.

Evaluation:

Was the goal met, in progress or unmet?

Explain?

Nursing Diagnosis:

(NANDA)

Psychosocial (1)

Planning/Outcome

(Goal)

Short Term:

Long Term:

Nursing Actions

(Interventions)

1.

2.

3.

4.

Rationales:

1.

2.

3.

4.

Evaluation:

Was the goal met, in-progress or unmet?

Explain?

Nursing Diagnosis:

(NANDA)

Psychosocial (2)

Planning/Outcome

(Goal)

Short Term:

Long Term:

Nursing Actions

(Interventions)

1.

2.

3.

4.

Rationales:

1.

2.

3.

4.

Evaluation:

Was the goal met, in-progress or unmet?

Explain?

Medical Diagnosis:

Pathophysiology of disorder:

References

RESEARCH ARTICLE (Please Attach)

Author(s)-must be written by at least one nurse:

Year (no later than the last 5 years):

Journal Name:

Volume, Issue, and Pages:

Title:

Summary of article in your own words, and how to best incorporate in your plan of care.

______ _____________________________________________________________________________________________________

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