Clinical Care Plan Expectations

 Include the Following Data:

 FLOWSHEETS:

 V/S: (measured by me), Not Others

 Head – to – Toe Assessment

 IV/PICC site, Gauge, Dressing Condition – IV Fluid (Meds/Blood products)

 Tubes: Oxygen, Tube Feeding, NG (Size) – Suction Setting, G-Tube, F/C, (Size), Pure Wick,

Drains

 Dressings, Wounds, Pressure ulcers

 Include: (Measurements if Appropriate)

 How Pt Ambulates

 Side Rails Up? If Yes – How Many

 Pain Rating 1-10, Location, Duration, Type

 MEDICATIONS :

 Trade & Generic Name, Indications, Side Effects, Nursing Implications, Contraindications

 LABS:

 Include normal Range & Value w/Proper Units

 List: (the Purpose for Each Lab) & (Rationale for Abnormal Lab Findings)
 Clinical Care Plan Expectations

 CARE PLANS:

 ASSESSMENT:

 Only Include Abnormal, Pertinent or Related to Your Diagnoses

 Clearly Separate them Into:

 Objective (Measurable)

 Subjective (what pt States/Concerns)

 NURSING DIAGNOSIS/PROBLEM:

 Accurately Interpret the Data Collected

 Include – “Related To” & “As Evidenced By”

 PT – OUTCOMES/PLANNING:

 Short-Term - SMART goals

 SPECIFIC: (Specific info to the pt & to my Nursing Diagnosis)

 MEASURABLE: (Info that is Measured on Some type of Scale)

 ACHIEVABLE: (make sure the Intervention Is Achievable for the Pt)

 RELEVANT: (Info that Is Relevant to my Diagnosis Only)

 TIMELY: (Be Sure to Choose a Realistic Time – So I can Go Back to Evaluate if:

 Goal is – Met/Un-met – or – Partially-Met

 INCLUDE:

 Be Sure to ADD – Why Goal was Met/Un-met or Partially-Met.

 How I Am Going to Help my Pt Meet Their Goal

 Use a Measurable Scale

 INTERVENTIONS:
 Clinical Care Plan Expectations
 List at Least 4 Interventions

 & 4 Appropriate Rationales that I can:

 (Reasonably, Independently) do During my Time w/pt As a Nurse – such as;

 Using Incentive Spirometer, Turn/Cough & Deep Breath, Hand Hygiene, Evaluate

Extremities, Float Heels, Teach Diet, etc.

 LABEL Each INTERVENTION – & - Paired RATIONALE (Clearly)

 PRIORITIZE them In ORDER of Importance (What Will Kill My Pt Fastest)

 Be SURE to ADD Source/Page # for;

 Each Intervention/Rationale Pair

 Exp., (Author(s), Year, Page(s)

 EVALUATIONS:

 Clearly STATE – if Met/Un-Met – Partially-Met

 INCLUDE- Specific (Objective & Subjective Data) to Support My Evaluation

 PLAN -How to CONTINUE to IMPROVE pts CONDITION

 ADDITIONALE – INFORMATION:

 CITE – Full Sources Info