Ivy Tech Community College Northeast

Student Name ____________Date(s) of Care___ Patient Age ___

Patient Diagnosis ___Date of Surgery, if applicable____
(Circle one) Antepartum / Labor & Delivery / Postpartum Blood Type/ RH _________
G/T/P/A/L __________________ EDB _____________ Gestational Age_________________
Rubella (I) (NI); GBS (+) (-); HEP B (+) (-); HIV (+) (-); Marital Status ___________
Baby (M) (F) Birth WT _____________ Apgar _________
Gordons Functional Health Patterns

I.

Health History/Health Perception

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
II.

NUTRITION

METABOLIC

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

III.

ELIMINATION
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

IV.

ACTIVITY - EXERCISE
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

V.

SLEEP - REST
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

VI.

COGNITIVE - PERCEPTUAL
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

VII.

SELF PERCEPTION - SELF CONCEPT

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies

VIII.

ROLE RELATIONSHIP
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

IX.

SEXUALITY - REPRODUCTIVE
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

X.

COPING - STRESS TOLERANCE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

XI.

VALUES - BELIEFS
SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
DISCHARGE NEEDS

PATHOPHYSIOLOGY/ Disease Process (3)

Identify why the client was admitted and any changes that have occurred during this admission,
including response to current treatment modalities.

Identify the pathophysiology for the primary diagnosis and all interrelated diagnosis. Please be
sure to include:
o What is occurring in the body
o Signs and symptoms
o Anticipated/ordered diagnostic/lab studies
o Anticipated/ordered treatment modalities
o Nursing care

1.
2.
3.

Medications-including IV therapy: Medication, indication, dose range, pt dose, adverse reaction,

nursing considerations.
Medication

Indication

Dose Range

Patients Dose

Adverse Reaction

Nursing
Considerations

PRIORITIZATION OF NURSING DIAGNOSIS

List all nursing diagnosis in order of priority.
Note: It is expected that if a problem is listed as numbers 1, 2, or 3 that these problems would be
addressed in the Care Plan. At least one problem should be related to the pathophysiology, example: if
the care plan is a heart patient, at least one nursing diagnosis should be related to the heart disorder.

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:

Goal:

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:

Goal:

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Or, is it
appropriate to keep with the original plan?)

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(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis:

Goal:

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Or, is it
appropriate to keep with the original plan?)

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