Edyth T. James Department of Nursing Daily Clinical Log Client Name: _____________________________ Client’s Age: _________ Gender: ________________ Present Medical Diagnoses: ____________________________________________________________________________ Present Surgery (if applicable): _____________________ Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education): __________________________________________________________________________________________________________________________________________________________________ Spiritual Well-Being: _________________________________________________________________________________ Allergies: __________________________ Code Status: _________________________ Vital Signs: T_____________ P_____________ R____________ BP______________ SPO2__________ Physical Examination: General Appearance: Psychiatric: HEENT: Neck and Lymph Nodes: Pulmonary: Cardiovascular: Skin and Nails: Abdomen: Genitourinary: Pelvic and Rectal: Extremities: Musculoskeletal: Neurological (DTR’s, reflex grading, cranial nerve evaluation): Incisions: Drains: Diet/Nutrition: IVs: Intake and Output: Fall Risk Assessment (include score): Pressure Ulcer Risk Assessment (include score): Pain assessment (include reassessment): Time Score Intervention Reassessment Time Score Diagnostic Assessments – Important EKGs, X-Rays, and Labs: Lab/Other Test Patient values Inference Medications Ordered for Client: Medication and Dose with Brand name Generic Name of Drug Times of Administration Indications of Drug Adverse Effects Nursing Implications Treatment: Treatments and Procedures Day & Times Rationale Nursing Interventions: Assessment Findings Nursing Diagnoses Expected Outcomes Nursing Interventions Evaluation Reflections of the day: Edyth T. James Department of Nursing NURS 489 – Synthesis of Complex Nursing Care Clinical Care Plan 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: Descr ...

1. Edyth T. James Department of Nursing
Daily Clinical Log
Client Name: _____________________________
Client’s Age: _________ Gender: ________________
Present Medical Diagnoses:
_____________________________________________________
_______________________
Present Surgery (if applicable): _____________________
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital
status, children, religion, culture, ethnic group, and education):
_____________________________________________________
_____________________________________________________
_____________________________________________________
___
Spiritual Well-Being:
_____________________________________________________
____________________________
Allergies: __________________________ Code Status:
_________________________
Vital Signs: T_____________ P_____________ R____________
BP______________ SPO2__________
Physical Examination:
General Appearance:
Psychiatric:
HEENT:

2. Neck and Lymph Nodes:
Pulmonary:
Cardiovascular:
Skin and Nails:
Abdomen:
Genitourinary:
Pelvic and Rectal:
Extremities:
Musculoskeletal:
Neurological (DTR’s, reflex grading, cranial nerve evaluation):
Incisions:
Drains:
Diet/Nutrition:
IVs:
Intake and Output:
Fall Risk Assessment (include score): Pressure Ulcer
Risk Assessment (include score):
Pain assessment (include reassessment):
Time

3. Score
Intervention
Reassessment Time
Score
Diagnostic Assessments – Important EKGs, X-Rays, and Labs:
Lab/Other Test
Patient values
Inference

4. Medications Ordered for Client:
Medication and
Dose with Brand name
Generic Name of Drug
Times of Administration
Indications of Drug
Adverse Effects
Nursing Implications

5. Treatment:
Treatments and Procedures
Day & Times
Rationale

6. Nursing Interventions:
Assessment Findings
Nursing Diagnoses
Expected Outcomes
Nursing Interventions
Evaluation

7. Reflections of the day:
Edyth T. James Department of Nursing
NURS 489 – Synthesis of Complex Nursing Care
Clinical Care Plan

8. 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):

9. 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)
Definition:

10. Etiology:
Pathophysiology:
Signs & Symptoms:
Diagnostic test:
Treatment:
Section III
Assessment
(Points 20)
Physical Assessment:
General Appearance
Neurosensory
Psychosocial
Cardiovascular
Respiratory
Gastrointestinal

11. 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)

12. Section IV
Diagnostic Data
(Points 10)
Diagnostic Tests
Patient’s value
Normal Range
Inference (why is this patients value abnormal)

14. Section V
Treatment and procedures
List all interventions/nursing actions dependent (physician
initiated) and independent (nursing initiated) performed during
your clinical experience.
(Points 10)
Interventions
Rationale
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)

15. 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 (Points 10)
Medications
Medication
Dose/ Brand/
Generic Name
Mechanism of Action/Indication for Use
Contraindication
Adverse Effects/Side Effects
Nursing Implications
Outcomes

16. Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “3 ” (MINIMUM) NURSING DIAGNOSES
Assessment
findings
Nursing Diagnosis
(Actual & Potential Deficits, Wellness Diagnoses)
Outcomes
Short and Long Term
Interventions/ Nursing Systems

17. (Dependent & Independent)
Rationale
(Why are performing that intervention?)
Evaluation/ Outcome
(What was the actual result?)

18. School of Health Professions, Science and Wellness
Edyth T. James Department of Nursing
CLINICAL CARE PLAN GRADING CRITERIA
Course Number: ______________________________________
Name of Student: _____________________________________
Date:________________________________________________
Grading Criteria
Possible Points
Points Earned/Comments
SUBMISSION ON DUE DATE
5 Points
Section I

19. General Data, Health History, and Review of Systems
10 Points
Section II
Attached references in APA Format
5 Points
Pathophysiology of Disease Process
10 Points
Classic Signs and Symptoms of Disease Process
5 Points
Section III Physical Assessment
15 Points
Section IV Diagnostic Data
5 Points
Section V Treatments and Procedures
5 Points
Section VI Teaching and Health Promotion
5 Points
Section VII List of Nursing Diagnoses
10 Points
Section VIII Medications
5 Points

20. Section IX Care Plan with 4 minimum nursing diagnoses
20 Points
TOTAL POSSIBLE POINTS
100 Points
Name of Clinical Professor:
____________________________________________
Client Code Name: D L
Client's Age: os Gender: F
Present Medical Diagnoses: AFIB, HTN, hypothyroidism, chest
Pressure
Present Surgery (if applicable): NO
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital
status, children, religion, culture, ethnic group, and education):
Spiritual Well-Being:
Allergies: Alleres tetracy _____ Augmentin Code Status:
Vital Signs: T & 8 P 89. R 15 BP 120/80
SPO₂ A
_____________________________________________________
_____________________________________________________

21. Fall Risk Assessment (include score): Pain assessment (include
reassessment):
Time : 8am
Score :
Intervention :
Reassessment Time : 11am
Score : 0
Diagnostic Assessments-Important EKGs, X-Rays, and Labs
Lab/Other Test : WBC, RBC, HG?, HCF, PLATELET,
MONOCYTE
Patient values : 5-2, 2-52, 39-6, 87-2, 186, 7-2
Inference
Medications Ordered for Client:
Medication and Dose with : Aspirin, Famotidin, nebivolol,
enoxaparin
Generic Name of Drug : 81m, 40mg, 10mg, 100mg
Brand name : 9
Times of Administration
Indications of Drug
Adverse Effects

22. Nursing Implications
Treatments and Procedures : Pti Enoxaparin
Day & Times : 1 a day
Rationale : to treat blood clots
Nursing Interventions:
Assessment Findings : R
Diagnoses
Expected Outcomes
Nursing Interventions
Evaluation
Reflections of the day: