Department of Nursing
Clinical Care Plan
Adult Gerontology Health Nursing I
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: ____________
History of Present Illness (Detailed):
Past Medical/Surgical History:
Family History of Illness:
Description of Procedures (Surgeries) Performed this Admission:
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 )
Intake and Output
Pain assessment (include reassessment)
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Diagnostic Tests Patient’s value Normal Range Inference(why is this patients value abnormal)
Treatment and procedures
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
Teaching and Health Promotion
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
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.)
Medication DoseBrand/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?
CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES
Assessmentfindings Nursing Diagnosis(Actual & Potential Deficits, Wellness Diagnoses) OutcomesShort and Long Term Interventions/Nursing Systems(Dependent & Independent) Rationale(Why are performing that intervention?) Evaluation/Outcome(What was the actual result?)
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