Post – Baccalaureate Nursing Program
Clinical Nursing Care Plan
2019-2020

Introduction:  Introduce your patient (initials, age, sex, DOB, attending MD, history of current medical problem).

General statement:
Primary admitting medical diagnosis: CVA/ Seizures
Describe the pathophysiology of the patient’s condition; problems anticipated based on the pathophysiology.

Code status: Full Code

Allergy: Patient Response

Background:
Previous stroke, coronary artery disease, left side weakness

Carefully read -address this question.
Why is the patient here? In –turn why can this patient NOT go home (yet)? Vital signs are normal, but patient is experience left arm weakness. Family member used call light for right side symptoms of seizures.

Fostering Patient Centered Care:
What brought you here?

How does your illness impact your life?

Tell me about your life before your illness/hospitalization?

What are your greatest concerns?

What is your goal for today?

Analysis

Vital signs: Most recent assessment data showing trends (before your care of patient)
Dates/times: Your assessment data with times: (obtained when you care for the patient)
(show trending) Interpretation: What does the data mean*? *Describe how you know what you know –describe what the assessment data tells you –likely on a basic physiologic level. Support your understanding of the “why” of the data you have collected.

Analysis (Interpreting) (Complete this section before caring for your patient)

Summarize and explain:  What are the issues the medical team is working on with your patient, and what are their priorities?

What are the  (likely-anticipated) NURSING diagnoses for this patient?  List several.

Prioritize the top 2 (likely- anticipated) nursing diagnoses for this patient (3 part).   Give your rationale.

Identify 1 potential/risk for nursing diagnosis (2 part). Give your supporting rationale.

Nursing Care Plan
The nursing diagnoses listed here should reflect your final interpretations/prioritization of patient presentation (having now cared for the patient).

Evaluation (Reflecting) .How will you know if your nursing interventions are working?  How will you know if the patient outcomes are met?

Evaluation of outcome with supporting statement

Replanning:
Evaluation of outcome with supporting statement.