Gestational Diabetes Nursing Care Plan Worksheet

Page 1 of 10 Nursing Care Plan NURSING (AS) Program Student Name: ____________________________________ Date: ____ / ____/ ______ Initial: Sex: M / F Date of Admission: / / Admitting Diagnoses: 1) 2) 3) 4) 5) Patient Past Medical History: Instructor: __________________________ Clinical Site: _______________________________ Patient Information Age: Ethnic Group: Allergy: Weight: Past Surgical History: Social History: History of Present Illness: (If additional Space is needed please continue on the back of this page) NURSING CARE PLAN White / AA / Hispanic / Asian Diet: Page 2 of 10 Subjective Findings (If additional space is needed please continue on the back of this page) Vital Sign: BP: HR: RR: Objective Finding Temp: Physical Assessment Findings: Laboratory Studies: CBC etc.) NURSING CARE PLAN Metabolic Panel Coagulation Other: (U/A, ABG’s, Protombin, Page 3 of 10 Imaging Result: (X-Ray, CT Scan, MRI, MRCP, Ultrasound…….) Endoscopic Result: (colonoscopy, EGD…..) What is the relation between these diagnostic tests with the patients disease and or present illness? NURSING CARE PLAN Page 4 of 10 Analysis: What are the potential complications / problems for this patient? NURSING CARE PLAN Page 5 of 10 Medication List Medication/Order NURSING CARE PLAN Usage Usual Dose Side effects Nursing Intervention Page 6 of 10 Nursing Care Plan Once evaluated patient’s past and present history: select at least three nursing diagnoses from highest to lowest priority. Give nursing interventions (dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses. Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 7 of 10 Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 8 of 10 Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 9 of 10 Patient’s Care Plan Evaluation of Outcomes: NURSING CARE PLAN Page 10 of 10 Student Evaluation (To be completed by faculty only) Comments: Student Needs to Improve on: FINAL GRADE: _____________________ Instructor’s Signature: _____________________________ Date of evaluation: _________________ Student’s Signature: _______________________________ NURSING CARE PLAN