CUYAHOGA COMMUNITY COLLEGE

Department of Nursing Education

MINI NURING CARE !LAN "c#inica# prep form$
Student's Name: ________________________________________
GENERAL IN%ORMATION
Patient Initials __________ Date of Care __________
Source of Data:
1)__________ Patient 2) __________ Chart 3)________________ Family em!er
")__________ #ealth Care $eam %) __________ &ther
'(e __________ Se) __________ artial Status __________ 'dmission Date _________
*eli(ion ____________________ 'd+anced Directi+es ,Dura!le Po-er of 'ttorney for
#ealth Care. /i+in( 0ill. etc):
*eason for 'dmission:
11
21
31
"1
%1
21
Primary edical Dia(nosis
Secondary edical Dia(noses
Sur(ical 3rocedures and dates
Definition of medical dia(noses: *e3orted si(ns 4 sym3toms
,5se 3atient's o-n -ords)
S6s dia(noses as (i+en in your te)t!oo7
8rief descri3tion of !asic 3atho3hysiolo(y of 3resentin( condition,s)
9DIC'$I&NS 'ND $*9'$9N$S:
NURING CARE !LAN "NURING !ROCE$
AEMENT ANALYI GOAL INTER&ENTION 'ITH E&ALUATION 'ITH
RATIONALE U!!ORTING
O(ER&ATION
Data collected from Nursin( Dia(nosis /on( $erm and Short Nursin( 'ctions and Scientific 9+aluation of (oals:
;'nalysis of Self< $erm *ationale -ith Cited *eference Continue. odify.
Care Discontinue Plan
Ca3a!ilities6Deficits;