care plan medsurg

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School of Health Professions, Science and Wellness
Department of Nursing
Clinical Care Plan
Adult Gerontology Health Nursing I
Semester: ___________________
Total points awarded: __________________
Student: ____________________________________ Date: __________________
______________________________
Instructor: ______________________________
Section I
General Data
(Points 5)
Client’s Initials: _____________ Age: _________ Sex: ________ Room#: ________________
Date of Admission: ________________
Date of Care: _____________________________
Present Medical Diagnoses: ____________________________________________________
Present Surgery (if applicable): ________________Date of Surgery: ______________
Allergies: __________________________
Code Status: ________________________
Section II
Recognizing Cues
(Points 15)
Height: ________
Weight: _________
NOTICING – UTILIZING OBSERVATIONS TO RECOGNIZE PATTERNS, AND GATHER INFORMATION.
RECOGNIZING CUES – The mental process involved in identifying relevant and important information
60 second initial visual assessment
(completed while receiving report and prior to physically assessing patient)
What do you
see?
Visual cues such
as room
cleanliness,
hygiene of
patient, IV pump,
O2, other lines,
drains, tubes.
Focused Physical Assessment
Recognize abnormal vs. normal – Recognizing signs and symptoms
What is your
client’s admitting
diagnosis?
What will you
focus on based
on this
information?
Perform
appropriate
focused
assessment.
Include the
findings of your
focused
assessment
Include the
pathophysiology
of the client’s
admitting
diagnosis,
including the risk
factors,
signs/symptoms,
diagnostics,
prognosis, and
treatments. You
must include a
resource for this
information. (1-2
pages)
Identify History Of
Medical/Surgical/Home Medication/Social, Occupational History cues
Recognize contributing past history
Interview your
patient.
What is their
pertinent
medical/surgical
history?
What home meds
do they take?
Where do they
work, live,
socialize?
Vital Signs, Lab Values and Diagnostics
Recognize abnormal vs. normal as well as pertinent information related to patient diagnosis
Temp:
Blood Pressure:
Document the
patient’s vital
Heart Rate:
signs.
Include reasoning
Respiration:
for any abnormal
vital signs.
Pain:
Examine your
patient’s
Electronic
Medical Record.
What are the
pertinent lab
values given the
admitting
diagnosis and
current condition
of your patient?
Lab
Value
Normal
Range
Patient’s
Lab Value
Result
Reason for Abnormal Value
What diagnostic
tests has the
client
undergone?
Include the
results of the
test.
Section III
Analyzing Cues & Prioritize Hypothesis
(Points 30)
INTERPRETING – MAKING SENSE OF THE DATA AND PRIORITIZING INFORMATION
UTILIZING YOUR REASONING ABILITIES TO INTERPRET THE FACTS AND FORSEE POSSIBLE INTERVENTIONS
ANALYZING CUES – clustering and linking related information to create groups of individual cues
PRIORITIZE HYPOTHESIS – Evaluate and rank potential causes or risk factors to address
Based on findings from 60 second initial visual assessment
Hypothesize regarding needed interventions
What will require action?
Prioritizing action (i.e. bathe
patient, tidy room, fluid
replacement, adjust O2 etc)
Based on findings from Focused Physical Assessment
Analyze and form hypothesis for future action
What assessment findings are
most concerning?
What makes you say that?
Are there any findings that
seems contradictory? (i.e.
findings that may point to an
alternative or additional
concern)
What findings are consistent
with admitting diagnosis?
Based on Identifying History Of
Medical/Surgical/Home Medication/Social, Occupational History cues
Analyze and form hypothesis for future action
What findings did you expect
based on the client’s
diagnosis/concern?
What medications would you
expect based on the client’s
diagnosis, concern, history?
Are there any findings that seem
contradictory? (i.e. meds
expected but not present, meds
present but not expected,
assessment findings without
interventions)
What else could be going on?
Based on Vital Signs, Lab Values and Diagnostics
Analyze and form hypothesis for future action
What will require action? (i.e.
b/p requiring treating, increase
or decrease O2, treat electrolyte
imbalance, intervene regarding
fluid volume status, etc.)
GENERATE SOLUTIONS – Generate a set of feasible solutions to handle emergent concerns based on prioritized
hypothesis above
Things to address?
Things to avoid?
What interventions are
indicated?
Which hypothesis is the most
important and should be
managed first?
What makes you say this?
Medication Sheet (10 points)
Medication Dose
Generic Name
Mechanism of
Action/Indication
for Use
Contraindication
Adverse
Effects/Side
Effects
Nursing
Implications
Outcomes
Section IV
Responding & Taking Action
(Points 25)
RESPONDING – UTILIZING YOUR CLINICAL JUDGMENT TO MAKE DECISIONS AND JUDGMENTS
TAKE ACTION – Implementation of the solutions based on generated hypothesis
Based on generated solutions
What are the critical safety
issues and what did you do
to protect the client?
What interventions are
needed immediately? How
will you implement them?
What interventions can be
delegated and to whom?
What specific items will you
teach the client? Health
teachings given?
How did you respond to
patient, family and
caregivers?
Section IV
Reflecting & Evaluation
(Points 25)
REFLECTING – EVALUATION OF PERSONAL EXPERIENCE AND UTILIZING JUDGMENT SKILLS
EVALUATING OUTCOMES – Understanding signs of clinical improvement or decline and reflecting on the
effective outcomes of interventions
What follow-up data are
needed?
What findings show
interventions have been
effective?
What interventions require
formulating a new
hypothesis?
What values show a need for
continued monitoring (i.e.
labs, vital signs, interventions)
What went well and what did
not go well and why?
What would you do
differently?
What priorities, skills do you
think you need to improve in
order to care for future
patients?
References: (5 Points)