careplan final
6
1
School of 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)
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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.
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Human Needs |
Nursing Diagnoses (Circle Selected Nursing Diagnoses) |
Nursing Diagnoses Statements |
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Oxygenation 1. Perfusion (Cardiac) 2. Acid Base Balance 3. Ventilation 4. Diffusion |
Decreased Cardiac output
Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral |
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Fluid & Electrolytes Balance 1. Acid Base Balance 2. Metabolism 3. Intracranial Regulation |
Liquids, excess volume |
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Elimination |
Constipation |
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Nutrition 1. Energy 2. Cellular structure and function 3. Failure to Thrive 4. Metabolism |
Nutrition, altered: excess |
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Sleep |
Sleep pattern disturbance |
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Mobility |
Disuse, high risk of syndrome Self-care, deficit: dressing / grooming |
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Sensation and Cognition 1. Mood and affect 2. Tissue integrity |
Sen-so-perceptual alterations (specify) visual Tissue, impaired integrity |
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Rest and Comfort 1. Pain 2. Stress and Coping 3. Fatigue |
Coping: ineffective Anxiety |
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Spiritual Integrity 1. Grief and loss 2. Cultural |
Spiritual suffering |
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Affiliation 1. Love and Belonging 2. Social Support Systems 3. Self-Actualization |
Verbal, disorder Recreation, deficitRole, impaired performance |
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Sexual Integrity 1. Reproductive Health 2. Sexual Relationships 3. Sexuality |
Sexual dysfunction |
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Safety 1. Infection and Inflammation 2. Immunity 3. Substance abuse 4. Abusive environments |
Infection, high risk of |
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Self-Esteem 1. Developmental milestones across the lifespan 2. Health promotion/health beliefs 3. Behaviors 4. Teaching and learning |
Growth and development, altered Coping familiar development potential Coping:ineffective Health, generating conducts (specify) Treatment, tracking no (specify) Therapeutic regimen, ineffective management of (individual) |
Section VIII
Medications
(5 Points)
Medication Sheet
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Medication Dose Brand/ Generic Name |
Mechanism of Action/Indication for Use |
Contraindication |
Adverse Effects/Side Effects |
Nursing Implications |
Outcomes |
Safe Dose (yes or no) Why is your client on the drug? |
Section IX
Nursing Interventions
(Points 20)
CARE PLAN FOR “ 4 ” (MINIMUM) NURSING DIAGNOSES
|
Assessment Findings |
Nursing Diagnoses (Actual & Potential Deficits, Wellness Diagnoses) |
Outcomes
Short and Long Term |
Interventions/Nursing Systems (Dependent & Independent) |
Rationale (Why are you performing that intervention?) |
Evaluation/Outcome (What was the actual result?) |