Clinical Care Plan
Health Professions, Science and Wellness
Department of Nursing
Clinical Care Plan
Student: _____________________ Date: __________________
Submission of clinical care plan on due date (5 Points)
Instructor: __________________ Clinical Course: __________
Client’s Code Name: Age: Gender:
Primary Medical Diagnosis: ________________________________________
Secondary Medical Diagnoses: ______________________________________
Present Surgery (if applicable): _________ Date of Surgery: __
Allergies and Symptoms They Cause: _________________________________
Height: Weight: _
Code Status: ____________
Section I
General Data, Health History, and Review of Systems
( 10 Points)
Biographical Data:
Chief Complaint:
History of Present Illness (Detailed):
Past Medical/Surgical and Injury History:
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
Spiritual Well-Being:
Family History of Illness:
Immunization History:
Developmental Stage in Life:
Description of Procedures (Surgeries) Performed this Admission:
Review of Systems – brief history of each system and use abbreviated format, not complete sentences
General:
Psychiatric:
Skin, hair, and nails:
Lymph nodes:
HEENT (head, eyes, ears, nose, mouth, throat):
Neck:
Blood:
Breasts:
Cardiovascular:
Respiratory:
GI:
GU:
Musculoskeletal:
Neurologic:
Endocrine:
Section II
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan ) References done in APA Format (5 Points)
Pathophysiology of Disease Process
(Points 10)
Classic Signs and Symptoms of Disease Process
(5 Points)
Section III
Physical Assessment
(15 Points)
Physical Assessment:
Vital Signs (T, P, R, BP, SPO2)
General Appearance
Psychiatric
HEENT
Neck
Breasts and Lymph Nodes
Pulmonary
Cardiovascular
Skin and Nails
Abdomen
Genitourinary
Pelvic and Rectal
Extremities
Musculoskeletal
Neurological (DTR’s, reflex grading, cranial nerve evaluation)
Incisions
Drains
Diet/Nutrition
IVs
Intake and Output
Pain assessment (include reassessment)
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Section IV
Diagnostic Data
(5 Points)
Inlcude pertinent diagnostic tests, including labs, EKG, and X-Rays
Diagnostic Tests
Patient’s value
Normal Range
Inference(why is this patients value abnormal)
Section V
Treatments and Procedures
List all treatment and procedure interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
( 5 Points)
Treatments and Procedures
Day & Times
Rationale
Section VI
Teaching and Health Promotion
( 5 Points)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
Section VII
(5 Points)
List of Nursing Diagnoses (Minimum of 5) Use your assessment of your client’s human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.
Human Needs
Nursing Diagnoses
(Circle Selected Nursing Diagnoses)
Nursing Diagnoses Statements
Oxygenation
Perfusion (Cardiac)Acid Base BalanceVentilationDiffusion
Decreased Cardiac output
Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral Impaired Gas exchange Ineffective airways cleaning Ineffective Respiratory pattern Difficulty maintaining spontaneous ventilation, Respiratory dysfunctional response to Weaning High risk of Asphyxia High risk of Aspiration
Fluid & Electrolytes Balance
Acid Base BalanceMetabolismIntracranial Regulation
Liquids, excess volume Liquids, Volume Deficit Liquids, high risk of volume deficit Body temperature: high risk of impaired Hypothermia Hyperthermia Ineffective Thermoregulation
Elimination
Constipation Subjective Constipation Chronic Constipation Diarrhea Fecal Incontinence Urinary, impaired elimination Urinary incontinence: stress Urinary Incontinence: reflects Urinary Incontinence: emergency Urinary Incontinence: Functional Urinary Incontinence: total Urinary, retention Self-care, deficit: use the potty / toilet
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