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Nursing Assessment Guide and Care Plan

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Nursing Assessment Guide and Care Plan
Date: ______ Student’s Name: _______________ Course: ____________
Clinical Site: ____________ Instructor’s Name: __________
Age: ____ Ethnicity: ____ Sex:___ Date of Admission: _______
Chief Complaint: ______________ Ht.:________ Wt.: _______
Admitting Diagnosis:
_______________________________________________________
Allergies: _____________ Diet:
_____________________________________
Primary Language: _________________________ Marital Status:____________
Vital Signs B/P: _____ P: _____R: ____ T: _____Pain Scale Score:____ Pulse Ox:___
Brief Descriiption of Condition:
Medical/Surgical History: (Medical illnesses, previous hospitalizations, surgeries,
injuries, immunizations)
Family History: (Family illnesses, especially parents, siblings, children)
Psycho-social Assessment: (Education, employment, smoking, living arrangements,
religion or spirituality)
THE NEW YORK INSTITUTE OF TECHNOLOGY
SCHOOL OF HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURSING CARE PLAN Student name: ______________________________
Date: _________________________________
Care Plan # ___________________________ Patient Initials: _________ Developmental Stage: ________________________
NAME: DATE: HOSPITAL: UNIT:
Nursing Diagnosis # 1
ASSESSMENT DATA :
Objective Data:
Subjective Data
Nursing Diagnosis Expected Outcome/Goals Nursing Interventions Rationale Evaluation

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