Comprehensive Patient Care Plan: An Integrated Approach to Nursing Diagnosis, Intervention, and Evaluation

Patient Care Plan

Patient Demographics

Health History

History of present illness:

Past Medical History:

Surgical History:

Social History:

Diagnostic procedures:

Surgical procedures:

Labs:

Diet with rationale:

Activity order:

Limitations/prosthetic devices:

Current medications:

Nursing Diagnoses

Nursing Diagnosis 1

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Diagnosis 2

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Diagnosis 2

R/T:

AEB:

Rationale: Should support the nursing diagnosis

Nursing Interventions

Nursing Diagnosis 1

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Nursing Diagnosis 2

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Nursing Diagnosis 3

· Include interventions done to assist the patient related to the abovementioned nursing diagnosis.

Evaluation

Explain if and how the interventions worked for the patient.

Discharge Planning

Write a discharge plan for this patient.

Pathophysiology

Write a brief summary regarding this patient’s main diagnosis as if you were explaining it to the patient.

References

References should be no older than 5 years and in APA 7 format.