Nursing Care Plan: History of present illness including admission diagnosis & chief complaint (normal & abnormal) supported by evidence-based citations physical assessment findings including presenting signs and symptoms supported with evidence-based citations relevant diagnostic procedures/results & pertinent lab tests/values (with normal ranges) include dates and rationales supported with evidence-based citations past medical & surgical history, pathophysiology of medical diagnoses (include dates, if not found state so) supported by evidence-based citations Erikson’s developmental stage with rationale and supported by evidence-based citations socioeconomic/cultural/spiritual orientation & psychosocial considerations/concerns supported with evidence-based citations (3 lists) Potential health deviation, predisposing & related factors (at least two) include three independent nursing interventions for each (“at risk for… ” nursing dx) Inter-professional consults, discharge referrals, and current orders (include diet, test, and treatments) with rationale supported with evidence-based citations Priority nursing diagnosis (at least 2) written in three-part statement
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