Clinical Care Plan

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



Skin, hair, and nails:

Lymph nodes:

HEENT (head, eyes, ears, nose, mouth, throat):











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




Breasts and Lymph Nodes



Skin and Nails



Pelvic and Rectal



Neurological (DTR’s, reflex grading, cranial nerve evaluation)





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


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


  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


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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