Medical Surgical Care Plan Assignment
Just fill in the blank the attach document on file. Noted: Nursing Diagnosis should be based on NANDA. Thank you.
Department of Nursing - Clinical Care Plan
Section I - General Data, Health History, and Review of Systems.
Review of Systems - brief history of each system and use abbreviated format, not complete sentences.
Section II - 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) References done in APA Format.
Section III - Physical Assessment
Section IV - Diagnostic Data. Include pertinent diagnostic tests, including labs, EKG, and X-Rays.
Section V - Treatments and Procedures
List all treatment and procedure interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
Section VI - Teaching and Health Promotion
List client's teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
Section VII - List of Nursing Diagnoses (Minimum of 5) Use your assessment of your client's human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.
Section VIII - Medications
Section IX - Nursing Interventions
Attachment:- Clinical Care Plan.rar