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