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Running head: CLINICAL CARE PLAN

Clinical Care Plan


Course Number

_________________

Course Name

_________________

Student Name

_________________

Instructor Name

_________________

Date

STC 201625

_________________

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

Running head: CLINICAL CARE PLAN

Assessment
This information is
derived from your data
collection sheets (your
physical assessment
findings, HPI, subjective
data, chart reports etc.)
and is the data that
supports your chosen
nursing diagnoses.

Nursing Diagnosis
Consult Ackley to select
a nursing diagnosis that
is a high priority for the
health and well being of
your patient. Consider
your patients S&S,
medical diagnoses,
functional status, risk
factors, lab and
diagnostic data.

Plan (Goals)
Planning consists of
setting measurable and
realistic goals. (Then
choosing the
appropriate
interventions to help
meet those goals.)

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 patients
needs.

Supporting Subjective
Data:

#1)

ND #1:
The patient will:
1)

Assessment
interventions: What
physical, emotional,
knowledge base
assessments need to
be done on an
ongoing basis?

related to (list
causative or
contributing factors):
Supporting Objective
Data (assessment,
diagnostic, lab data
that supports your
nursing diagnoses.):

Cultural/Psychosocial
Background:
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as manifested by
(list the
signs/symptoms that
led you to choose
this diagnosis.):

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
patients response to
your interventions,
answer: 1) Has my
patients condition
improved? 2) Has my
patients knowledge
level improved? 3) And,
have I seen any change
in my patients
behavior?

ND #1:
1)

2)

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,
promote health and
health maintenance,
and prevent
complications?
Teach:
Safety: What are the
safety concerns?
What actions can you
take to prevent
STC 201625

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

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:

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Running head: CLINICAL CARE PLAN


Medications:

Teach:

Safety:

Reference

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