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Chief Complaint: History of Illness: Past History: Family History: Social Data: Psychological Data: Adm.Medical Diagnoses: ASSESSMENT Subjective Data Objective Data
DIAGNOSES
Nursing Diagnosis(es):
P L Interventions A. N N I N G
Rationales
E V A L U A T I O N
Clients response to each intervention (If modifications necessary, what intervention would be appropriate?)
Was the desired outcome achieved? (Met unmet, partially met) Why?
Physiological
Physiological
Psychosocial
Psychosocial
DRUG NAME
ACTION
DOSE
SIDE EFFECTS
NURSING CONSIDERATIONS