Brain

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)

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 1. Perfusion (Cardiac) 2. Acid Base Balance 3. Ventilation 4. Diffusion	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 1. Acid Base Balance 2. Metabolism 3. Intracranial 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
Nutrition 1. Energy 2. Cellular structure and function 3. Failure to Thrive 4. Metabolism	Nutrition, altered: excess Nutrition, altered: by default Nutrition, potential alterations: excess Self-care, deficit: feeding Swallowing, impaired Ineffective Breastfeeding interrupted breastfeeding Effective Breastfeeding Infant Feeding ineffective pattern
Sleep	Sleep pattern disturbance
Mobility	Disuse, high risk of syndrome Physical mobility, disorder Peripheral Neurovascular, high risk of dysfunction Activity intolerance Activity, high risk of intolerance Self-care, deficit: dressing / grooming
Sensation and Cognition 1. Mood and affect 2. Tissue integrity	Sen-so-perceptual alterations (specify) visual auditory, kin esthetic, gustatory, tactile, olfactory. Tissue, impaired integrity Oral mucous membrane, altered Skin, impaired Cutaneous, high risk of deterioration of the integrity Self-care, deficit: bathing / hygiene
Rest and Comfort 1. Pain 2. Stress and Coping 3. Fatigue	Coping: ineffective Anxiety Fear FatigueTransfer, stress syndrome Pain Chronic Pain
Spiritual Integrity 1. Grief and loss 2. Cultural	Spiritual suffering HopelessnessImpotence Bereavement dysfunctional Early Mourning
Affiliation 1. Love and Belonging 2. Social Support Systems 3. Self-Actualization	Verbal, disorder Social, impaired interaction Social isolation Coping: ineffective Recreation, deficitRole, impaired performance Parenteral, alteration Parenteral, high risk of disruption Parenteral, role conflict Adaptation disorder Family, alteration processes Role of caregiver, overexertion in The role of caregiver, high risk to overuse in the Defensive coping Denial ineffective Ineffective family coping: disabling Ineffective family coping: engaged
Sexual Integrity 1. Reproductive Health 2. Sexual Relationships 3. Sexuality	Sexual dysfunction Sexuality, altered patterns of
Safety 1. Infection and Inflammation 2. Immunity 3. Substance abuse 4. Abusive environments	Infection, high risk of Dysreflexia Injury, high risk Poisoning, high risk of Trauma, high risk of Protection, impaired engaged Violence, high risk: self-injury, injury to other Self-mutilation, high risk of Post-traumatic response Rape, traumatic syndrome of Violation, trauma syndrome: compound reaction Violation, trauma syndrome: silent reaction
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 Knowledge, deficit (specify) Thought, alteration processes Health, generating conducts (specify) Treatment, tracking no (specify) Decisions, conflict in the making (specify) Therapeutic regimen, ineffective management of (individual) Home, difficulties in maintaining Health, alteration in the maintenance of Body Image, disorder Self-esteem disorder Self-esteem, lack of: chronic Self-esteem, lack of: situational Personal, disorder

Section VIII

Medications

(5 Points)

Medication Sheet

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?)

 

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