CARE PLANNING AND CLINICAL REASONING

Plan of Care
Subjective Data: What did patient say? Use direct quotes. (abnormal) (Comes from patient and/or significant others)
Cluster significant data by 3 concepts and assign a Nursing Problem to each:
Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

Step 2: Identify Concept that data describes

Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

Step 2: Identify Concept that data describes

Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

Step 1: Cluster/Cue similar S/Ss, DCs data (minimum is 3 data items)

Step 2: Identify Concept that data describes

Step 3: Identify Nursing Problem (that describes the concept and prioritize below)

Clinical Reasoning:
1. List nursing problems from highest priority #1 to lowest priority #3 based on your clustered data, concepts, and
problems identified above:

1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
2. Based on your patient’s current status, what problem concerns you the most at this moment in time and
why?

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Collaborative Nursing Care

3. Based on this priority, what is your goal for this patient?

_______________________________________________________________________________________

4. Based on this priority plan your care for this patient:

Expected Outcomes: Nursing Interventions: Rationales: Evaluations:

5. What diagnostic results are relevant and clinically significant? List and give significance.

6. What Vital Sign(s) data are relevant and clinically significant? List and give significance.

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7. What is the most likely complication to anticipate? What assessment should you make? What
intervention(s) should you do?

8. When evaluating the patient, how will the nurse know the patient is getting better or worse?

9. Did your patient achieve the goal set for them? If not, what revisions in care

Education Priorities/Discharge Planning

1. What will be the most important discharge/education priorities you will reinforce with their medical
condition to prevent future readmission with the same problem?

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 2. How is the effectiveness of the teaching assessed by nurse?

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling about their current state of health/hospitalization?

2. What can you do to engage yourself with this patient’s experience, and show they are important to you
as a person?

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