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Running head: CLINICAL CARE PLAN

Clinical Care Plan
Course Number

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Course Name

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Student Name

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Instructor Name

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Date

STC 201625

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2 Running head: CLINICAL CARE PLAN Pathophysiology of medical diagnosis: Etiology of Medical Diagnosis: Expected Findings: Physical Assessment: Laboratory Data: (includes blood work. x-rays etc…) STC 201625 .

(Then choosing the appropriate interventions to help meet those goals.) and is the data that supports your chosen nursing diagnoses. emotional. lab and diagnostic data. medical diagnoses. chart reports etc. Nursing Diagnosis Consult Ackley to select a nursing diagnosis that is a high priority for the health and well being of your patient. functional status. answer: 1) Has my patient’s condition improved? 2) Has my patient’s knowledge level improved? 3) And.): Cultural/Psychosocial Background: STC 201625 as manifested by (list the signs/symptoms that led you to choose this diagnosis. HPI. Consider your patients S&S. have I seen any change in my patient’s behavior? ND #1: 1) 2) . diagnostic. Supporting Subjective Data: #1) ND #1: The patient will: 1) Assessment interventions: What physical. Plan (Goals) Planning consists of setting measurable and realistic goals.): 2) Nursing actions: What actions do I need to take? Collaborative interventions: What interdisciplinary team members do I need to consult with? What medically related (physician ordered) Evaluation (of Goals) To evaluate the patient’s response to your interventions. lab data that supports your nursing diagnoses.) Interventions (with Rationales) 1) Assessment 2) Nursing Actions 3)Collaborative 4)Medication 5)Teaching 6)Safety These interventions must be personalized and individualized to meet your patient’s needs. risk factors. subjective data. knowledge base assessments need to be done on an ongoing basis? related to (list causative or contributing factors): Supporting Objective Data (assessment.3 Running head: CLINICAL CARE PLAN Assessment This information is derived from your data collection sheets (your physical assessment findings.

and prevent complications? Teach: Safety: What are the safety concerns? What actions can you take to prevent STC 201625 . promote health and health maintenance.4 Running head: CLINICAL CARE PLAN interventions are needed? Which medications that the patient has ordered can be utilized to asst in attaining patient goals? And what actions and assessments/labs need to be monitored to make sure these medications are both safe and effective? What teaching to patient or family needs to occur to keep them informed re: this problem.

5 Running head: CLINICAL CARE PLAN injury. promote safety and security? #1) ND #1: The patient will: 1) Assess: ND #2: 1) related to Do: as manifested by 2) 2) Collaborative: Medications: STC 201625 .

6 Running head: CLINICAL CARE PLAN Teach: Safety: Student Name ________________________ #2) ND #2: The patient will: 1) Assess: ND #2: 1) related to Do: as manifested by 2) 2) Collaborative: STC 201625 .

7 Running head: CLINICAL CARE PLAN Medications: Teach: Safety: Reference STC 201625 .