Student Name: ________________________

________________________

Date :

Instructor:
________________________
__________________

Care Plan No:

Clinical Site:
________________________
Rotation: _______________

Clinical

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

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document objective and observable data such as: body language, facial
expressions, gestures, body positioning, ect.

Objective Data: (Attach clinical assessment form and provide a

summary of each system)
System
Summary
Psychosocia
l:

Neuorosens
ory:

Cardiovascu
lar:

Respiratory
:

Gastrointes
tinal:

Genitourina
ry:

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:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___
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Nursing Diagnosis 4:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___

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

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Intervention

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Rationale

Outcome
Evaluation

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

Student Documentation
Using the PIE method, document a note that would be included in the
patients chart based on one or more of the following factors:
Medical Condition
Needs
Psychosocial Needs

Nutritional Needs
Spiritual Needs

Laboratory/Diagnostic Results

Teaching

Cultural Needs/Implications

Pharmacological Interventions

Example:
P = Problem (Based on Subjective or Objective Data)
I = Intervention
E = Evaluation
P
_____________________________________________________________________________
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.
I 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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Plan Template
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Laboratory Data
Date

Test

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Patient
Result

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Normal/Abno
rmal

Normal
Range

Test
Description

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Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Medications
Drug/Class
(Dose, Route &
Frequency)

Action

Contraindications

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

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Side Effects

Nursing
Interventions

Patient
Teaching

Clinical Instructor Grading Sheet

Care Plan Strengths

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

Other:

Care Plan Template

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:

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Instructor Signature:________________________________________________
Date:__________________________________

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