care plano ree

Edyth T. James Department of Nursing

Daily Clinical Log

Client Name: _____________________________

Client’s Age: _________ Gender: ________________

Present Medical Diagnoses: ____________________________________________________________________________

Present Surgery (if applicable): _____________________

Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):

__________________________________________________________________________________________________________________________________________________________________

Spiritual Well-Being: _________________________________________________________________________________

Allergies: __________________________ Code Status: _________________________

Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________

Physical Examination:

General Appearance:

Psychiatric:

HEENT:

Neck 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:

Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score):

Pain assessment (include reassessment):

Time	Score	Intervention	Reassessment Time	Score

Diagnostic Assessments – Important EKGs, X-Rays, and Labs:

Lab/Other Test	Patient values	Inference

Medications Ordered for Client:

Medication and Dose with Brand name	Generic Name of Drug	Times of Administration	Indications of Drug	Adverse Effects	Nursing Implications

Treatment:

Treatments and Procedures	Day & Times	Rationale

Nursing Interventions:

Assessment Findings	Nursing Diagnoses	Expected Outcomes	Nursing Interventions	Evaluation

Reflections of the day:

Edyth T. James Department of Nursing

NURS 489 – Synthesis of Complex Nursing Care

Clinical Care Plan

Student: _________________________________ Date: ______________________________

Instructor: ______________________________ Clinical Course: ______________________

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

Date of Admission: ________________ Date of Care: _____________________________

Present Medical Diagnoses: ____________________________________________________

Present Surgery (if applicable): _____________________ Date of Surgery: ______________

Allergies: __________________________ Height: ________ Weight: _________

Code Status: ________________________

Section I

General Data

(Points 5)

Chief Complaint:

History of Present Illness (Detailed):

Past Medical/Surgical History:

Social History:

Family History of Illness:

Immunization History:

Description of Procedures (Surgeries) Performed this Admission:

Section II

Pathophysiology

(Points 10)

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)

Definition:

Etiology:

Pathophysiology:

Signs & Symptoms:

Diagnostic test:

Treatment:

Section III

Assessment

(Points 20)

Physical Assessment:

General Appearance

Neurosensory

Psychosocial

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Incisions

Drains

Diet/Nutrition

IVs

Vital Signs

Intake and Output

Pain assessment (include reassessment)

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Section IV

Diagnostic Data

(Points 10)

Diagnostic Tests	Patient’s value	Normal Range	Inference (why is this patients value abnormal)

Section V

Treatment and procedures

List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

(Points 10)

Interventions	Rationale

Section VI

Teaching and Health Promotion(Points 5)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

1)

2)

3)

4)

5)

Section VII (Points 5)

List of Nursing Diagnoses Use your assessment, the client’s medications, and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)

1)

2)

3)

4)

Section VIII (Points 10)

Medications

Medication Dose/ Brand/ Generic Name	Mechanism of Action/Indication for Use	Contraindication	Adverse Effects/Side Effects	Nursing Implications	Outcomes

Section IX

Nursing Interventions

(Points 15)

CAREPLAN FOR “3 ” (MINIMUM) NURSING DIAGNOSES

Assessment findings	Nursing Diagnosis (Actual & Potential Deficits, Wellness Diagnoses)	Outcomes Short and Long Term	Interventions/ Nursing Systems (Dependent & Independent)	Rationale (Why are performing that intervention?)	Evaluation/ Outcome (What was the actual result?)

School of Health Professions, Science and Wellness

Edyth T. James Department of Nursing

CLINICAL CARE PLAN GRADING CRITERIA

Course Number: ______________________________________

Name of Student: _____________________________________

Date:________________________________________________

Grading Criteria	Possible Points	Points Earned/Comments
SUBMISSION ON DUE DATE	5 Points
Section I General Data, Health History, and Review of Systems	10 Points
Section II Attached references in APA Format	5 Points
Pathophysiology of Disease Process	10 Points
Classic Signs and Symptoms of Disease Process	5 Points
Section III Physical Assessment	15 Points
Section IV Diagnostic Data	5 Points
Section V Treatments and Procedures	5 Points
Section VI Teaching and Health Promotion	5 Points
Section VII List of Nursing Diagnoses	10 Points
Section VIII Medications	5 Points
Section IX Care Plan with 4 minimum nursing diagnoses	20 Points
TOTAL POSSIBLE POINTS	100 Points

Name of Clinical Professor: ____________________________________________