BSN
NURSING PROCESS CARE PLAN
Student ______________________
Date
Course
NURSING DIAGNOSIS: Acute Pain R/T (Related to) post-surgical procedure AEB (as evidenced by) pancreatitis
PRIORITY #
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Subjective and Objective Data
1 Client Goal
(Goal must be timed and measurable) SMART
Interventions
(3 Nursing Interventions with Rationale and Reference for each)
Actual Completion of Nursing Interventions
Goal Evaluation
(met, not met, partially met and explanation)
Subjective
Objective
* Cite all interventions/rationales per APA format
NURSING DIAGNOSIS: Imbalanced Nutrition R/T inability to ingest food AEB chronic nausea.
PRIORITY #
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Subjective and Objective Data
1 Client Goal
(Goal must be timed and measurable) SMART
Interventions
(3 Nursing Interventions with Rationale and Reference for each)
Actual Completion of Nursing Interventions
Goal Evaluation
(met, not met, partially met and explanation)
Subjective
Objective
* Cite all interventions/rationales per APA format
NURSING DIAGNOSIS: Deficient Fluid volume r/t vomiting AEB Obstruction/Stenosis.
PRIORITY #
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
Subjective and Objective Data
1 Client Goal
(Goal must be timed and measurable) SMART
Interventions
(3 Nursing Interventions with Rationale and Reference for each)
Actual Completion of Nursing Interventions
Goal Evaluation
(met, not met, partially met and explanation)
Subjective
Objective
References
02/02/2021