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



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 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

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

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

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

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

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


(5 Points)

Medication Sheet

Medication Dose


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)




Nursing Diagnoses

(Actual & Potential Deficits, Wellness Diagnoses)


Short and Long Term

Interventions/Nursing Systems

(Dependent & Independent)


(Why are you performing that intervention?)


(What was the actual result?)

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