MEDICATION 

1.carvedilol 3.125mg  1tab po Q12h 

2.Darbepoetin alfa  60mcg= 0.3ml 

3. Heparin (subcut) 5000unit = 1ml Q8h 

4.hydralazine – isosorbide 1 tab po Q12h 20mg 

5.polyethylenegly col 3350 17mg powder po daily  

6. sacubitril valsartan (entrsto) 1 tab – 2x day 24mg 

7.sanna 17.2mg po daily  

8. torsemide 20mg po daily 

PATIENT DATE OF BIRTH  05/06/1947 

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School of Health Professions, Science and Wellness

Department of Nursing

Clinical Care Plan

Adult Gerontology Health Nursing I

Spring, 2017

Student: _________________________________ Date: ______________________________

Instructor: ______________________________ Clinical Course: ______________________

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

Date of Admission: ________________ Date of Care: _____________________________

Present Medical Diagnoses: ____________________________________________________

Present Surgery (if applicable): _____________________
Date of Surgery: ______________

Allergies: __________________________
Height: ________
Weight: _________

Code Status: ________________________

Section I

General Data

(Points

5)

Chief Complaint:

History of Present Illness (Detailed):

Past Medical/Surgical History:

Social History:

Family History of Illness:

Immunization History:

Description of Procedures (Surgeries) Performed this Admission:

Section II

Pathophysiology

(Points 10)

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan )

Section III

Assessment

(Points 20)

Physical Assessment:

General Appearance

Neurosensory

Psychosocial

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Incisions

Drains

Diet/Nutrition

IVs

Vital Signs

Intake and Output

Pain assessment (include reassessment)

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Section IV

Diagnostic Data

(Points 10)

Section V

Treatment and procedures

List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

(Points 10)

Section VI

Teaching and Health Promotion

(Points 5)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

1)

2)

3)

4)

5)

Section VII

(Points 5)

List of Nursing Diagnoses
Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)

1)
2)

3)

4)

Section VIII

Medications

(Points 10)

Medication Sheet

Section IX

Nursing Interventions

(Points 15)

CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES

Revised 8/12/2015