Name: ____________________________________ Client Initials: ____________ Rm #: ________

HARTNELL COLLEGE
G uidelines for N R N-44.1 C linical C are Plan Assignment

Student L earning O bjectives:

The student will
1. identify and utilize the nursing process in the assessment of clients with with multi-system failure
in the acute care setting.
2. identify the causes that affect client responses in Doenges and Moorhouse’s diagnostic divisions: 
Respiration: Circulation, Activity/Rest, Food/Fluid, Elimination, Safety, Neurosensory, Hygiene,
Pain/Discomfort, Ego Integrity, Social Interaction, Teaching/Learning, Sexuality, and Discharge
Considerations.
3. integrate the effects of age, culture, gender, socioeconomics, and religion into a nursing plan of
care for an adult client with multi-system failure.
4. cite and plan nursing practice consistent with the ANA Code of Ethics & Patient Rights;
5. relate basic nursing principles of pharmacology and medication administration to the adult client
with life threatening alterations.
6. plan and evaluate nursing care using the nursing process to promote client health and
wellness in the acute care environment.

Procedures:
1. With input from the clinical instructor, the student chooses two clients for study.
2. Students are required to demonstrate mastery of the nursing process by completing two
NRN-44.1 Clinical Care Plan Assignments to successfully complete the NRN-44.1
Nursing Clinical I course objectives. The components of the assignment include the
following:
E valuation Rubric for N R N-44.1 C linical C are Plan Assignment
Part A : N R N-44.1 C linical Data Collection Tool
Part B: N R N-44.1 M edication Wor ksheet
Part C : N R N-44.1 C are Plan Assessment Tool
Part D: N R N-44.1 L aboratory Studies Tool
Part E : N R N-44.1 Diagnostic T ests Tool
Part F : N R N-44.1 Nursing C are Plan
Part G : N R N-44.1 Reference list
3. Clinical Instructors will determine specific submission requirements and due dates.
4. Demonstration of mastery must be accomplished by receiving instructor feedback on the
first assignment before submitting the second assignment.
5. All written assignments must be complete and professional in appearance.
6. An unsatisfactory assignment will require resubmission or completion of an additional
assignment.
7. The components of the assignment are described:

1 
 
Name: ____________________________________ Client Initials: ____________ Rm #: ________

E valuation Rubric for N R N-44.1 C linical C are Plan Assignment

Attach the rubric to the Clinical Care Plan Assignment documents.

*Part A : N R N-44.1 C linical Data Collection and Four Q uestions Tool

M ust be completed for every assigned client. The original or copy of the tool for the client chosen for
study must be submitted with the Clinical Care Plan Assignment documents.

*Part B: N R N-44.1 M edication Wor ksheet

M ust be completed for every assigned client. The original or copy of the worksheet for the client chosen
for study must be submitted with the Clinical Care Plan Assignment documents. A worksheet must be
completed on all scheduled and prn medications. Evaluate and include the medication effectiveness after
the clinical experience.

Part C : N R N-44.1 C are Plan Assessment Tool

Part D: N R N-44.1 L aboratory Studies Tool
Part E : N R N-44.1 Diagnostic T ests Tool
These forms are completed for the Clinical Care Plan Assignment. The tools must be filled out completely.
Describe the relevance of the lab/test and the results to the client’s clinical status.

Part F : N R N-44.1 Nursing C are Plan

A. Assessment: Cluster data for the priority nursing diagnosis. Include clinical manifestations and causes.
Be sure the data provided is specific and individualized for your client while adhering to NANDA
approved guidelines.
B. Nursing Diagnoses: Identify and select 1 nursing diagnosis for the client from the NANDA list of
nursing diagnoses that most accurately describes the priority actual or potential health problems that have
been identified. Each care plan assignment must include different nursing diagnosis.
C. Goals: For each nursing diagnosis formulate a client goal (expected outcome). The goal statement
should be specific, measurable, realistic, and include the following 5 components – subject, active verb,
condition, criteria, and specific time frame.
D. Interventions: Determine nursing interventions that will achieve the established goal (expected
outcome) for the nursing diagnosis. Nursing interventions must be specific, realistic, and individualized.
Document a minimum of 3-4 interventions for each goal. Include focus assessments, teaching, and
prescribed treatments to help achieve the short-term goal/expected outcome.
E. Scientific Rationales: Rationales should explain the reason for doing each intervention. Briefly
paraphrase the rationale or “quote” the author.  Reference each rationale in the body of the care plan 
(author, date, pp. #). Also provide a reference list (APA format) for all references used in completing the
clinical assignment. See below.
F. Evaluation: Evaluate each short-term goal for the nursing diagnosis. State whether the goal has been
completely met, partially met, or not met at all and state why.

Part G : N R N-44.1 Reference L ist

Utilize nursing journals, medical-surgical textbooks and the Internet as references for pathophysiology
research, lab/diagnostic worksheet and rationales for interventions. A reference for APA formatting can be
found on the Hartnell College web site.

2 
 
Name: ____________________________________ Client Initials: ____________ Rm #: ________

HARTNELL COLLEGE
E valuation Tool for N RN-44.1 C linical C are Plan Assignment
Attach this form to your care plan.
*= Must be demonstrated in the plan of care

Satisfactory Needs Comments

Improvement
Submited Wor k O n T ime
Sections Complete
Part A : Clin. Data Collection Tool
Part B : M edication Wor ksheet

Part C : C are Plan Assessment

Tool
Part D: L aboratory Studies Tool
Part E : Diagnostic T ests Tool
Part F : Nursing C are Plan
A ppropriate Nursing Diagnoses
Data clustered: N A N D A
No ir relevant data in cluster
3-Part Statements for Nsg Dx
Relevant Goals
Interventions

*Demonstrated knowledge of
disease process or pathology
relevant to the nursing diagnoses
*Incorporated assessments,
teaching, counseling, or refer rals,
when applicable
*Individualized and integrated
prescribed Rx (meds. &
treatments)
*Included rationales (author/pg.
#) for each intervention
Professional presentation of wor k
Reference Sheet (AP A)

Strengths/A reas of Improvement: Resubmitted Materials

O n T ime: ______
L ate: _________

Resubmit by: ________

C linical Instructor:

3 
 
Name: ____________________________________ Client Initials: ____________ Rm #: ________

Date:

4 
 
Name: ____________________________________ Client Initials: ____________ Rm #: ________

HARTNELL COLLEGE
N R N-44.1 Portfolio: C linical Data Collection: Part A : Four
Q uestions To be completed prior to care.
C lient Initials: Room: Gender: Age: H t:
W t:

A dm Date: Hosp day#: P O D#: Projected D/C Date:

Prefer red L anguage: Religious/C ultural/Spiritual Preferences:

L evel of E ducation: O ccupation:

M Ds: Code Status: R x /Food/E nviron. A llergies:

A dm. M edical D x : Past Surgeries and Hospitalizations:

C ur rent/A dd. M edical D x :

Nursing D x : Nursing Goals:

Safety: Sensory A ids/

Side rails Impairments:
Restraints Prefer red L earning Style:
HRTF
O ther Assistive devices L ist_____________

B rief Description of Hospitalization (course and events):

5 
 
Name: ____________________________________ Client Initials: ____________ Rm #: ________

N R N-44.1 Portfolio: C linical Data Collection: Part A : Four Q uestions (cont.)

To be completed prior to care.

Pathophysiology and E tiology:

1. W hat are you on alert for with this client?

2. W hat are the important assessments to make?

3. W hat complications may occur? W hat could go wrong?

4. W hat interventions will prevent complications?

6 
 
 Name: _______________________________________ Client Initials:_____________ Rm#: _____________

N R N-44.1 Portfolio: C linical Data Collection: Part B: Medication Wor ksheet Page # _____ (Completed prior to care)
F ull Prescription C lassification/ Reason for R x Important Nsg Implications C lient Response
Generic /Trade Names Pharmacodynamic A ctions Therapeutic Effect/Use Side E ffects Specific for this client
Rx Times Specific for this client T eaching Points Effectiveness?
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration

7 
 
 Name: _______________________________________ Client Initials:_____________ Rm#: _____________

N R N-44.1 Portfolio: C linical Data Collection: Part B: Medication Wor ksheet Page # _____ (Completed prior to care)
F ull Prescription C lassification/ Reason for R x Important Nsg Implications C lient Response
Generic /Trade Names Pharmacodynamic A ctions Therapeutic Effect/Use Side E ffects Specific for this client
Rx Times Specific for this client T eaching Points Effectiveness?
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration
Classification:

Onset
Peak
Duration

8 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

HARTNELL COLLEGE:
N R N-44.1 Portfolio: Part C : C are Plan Assessment Tool
Instructions: All bolded sections require documentation. Complete the sections with boxes if
they apply to your client. Be as specific as possible. Use the back of the form if necessary.
N E UROSE NSORY
Subjective Reports: history of brain injury, trauma, stroke (residual effects), fainting, seizures,
headaches, etc:

L evel of Consciousness:

- -
Memory/Recall:
Concentration:

Reaction to L ight/A ccommodation:

V ision loss/change
H earing loss/change
T aste:
Smell:

Position Sense:
Consults:
Other:

R ESPIRA T I O N
Subjective Reports: hx of pneumonia, lung disease, lung tumors, trauma, use of 02, smoking, etc:

Respiratory Rate: Pattern: Rhythm:

B reath Sounds:
Wor k to B reathe: # Words b/w B reaths:
Strength of Cough:
Voice:
Prefer red Posture for O ptimal V entilation:
C hest E xcursion: C hest Shape: Upper A irway:

9 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Cough:

Air

Consults:
Other:

C IRC U L A T I O N
Subjective Report: hx HTN, heart disease, congenital heart disease, surgery, edema, arrhythmias, etc.

H eart Rate: A pical: Radial:

H eart Rhythm:
Blood Pressure: Range L ast 24 hours:
Sitting: Standing:
Peripheral Pulses: Location and G rade (0-4+):

C apillary Refill T ime:

Type:

Skin:

Distribution/quality of hair :
Varicosities:

Hct/Hgb pre transfusion: Hct/Hgb post transfusion:

Consults:
Other:

10 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

F O O D/ F L U I D
Subjective Report: usual diet, # meals/day, cultural food preferences, hx of gastrointestinal
disease/disorders/surgery/injury, etc.

Prescribed Diet: % Consumed:

L ast 8 hour: Intake: mL O utput: mL L ast 24 hours:

H eight: C ur ren
C alculated BSA :
:
arthria: Dysphasia:
M ucous M embranes:
Dental hygiene:

G ag/swallow reflex:

- -

Intravenous T herapy: Solution: Intake/24 hours:

Rate: drops/min Site: Pump Dial-a-flow
Consults:
Other:

ELIMINATION
Subjective Report: usual bowel/bladder elimination, hx disease/surgery/trauma, etc.

U rine: Color: Sediment: T urbidity: O dor:

11 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Type: Lumen Size: Balloon Size:

Residual urine per scan:

Other:
Stool: L ast B M :

Bowel Sounds:

Consults:
Other:

A C T I VI TY/R EST
Subjective Report: usual sleep/activity pattern, leisure activities, etc.

Prescribed A ctivity L evel:

G ait:
E ndurance: Posture:
VS Response to A ctivity:
Coordination: Balance:
E xtremity/Motor Strength: RUE: LUE: RL E: L L E:
Posture:

awning
Regular Sleep Pattern: Bedtime Rituals:
Range of Motion:

12 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Self-care Deficit:
Bed/A daptive E quipment:
Other:

SA F E TY
Subjective Reports: exposure to infectious diseases/toxins/poisons/radiation/toxins, recent travel, etc.

T emperature: A llergies and Description of Reaction:

Skin Integrity:

Site: Stage:
Size: Wound Edges:
devices:

ism:

A bility to Understand Instructions:

Risk for F alls:

Other

PA I N/D ISC O M F ORT

Subjective Report: hx of pain/discomfort, chronic pain, cultural expectations re pain perception and
expression, etc.

13 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

C ur rent L evel of Pain/Discomfort: Scale Used:

Client’s Description of pain/discomfort:  (onset, location, duration, intensity, radiation,

associating/aggravating factors:

PC A :

Pharmaceutic and Non-pharmaceutic Pain M anagement Measures:

O ther:

H YG I E N E
A bility to car ry out activities of daily living:

Independent/dependent
(level 1: no assistance needed to L evel 4, completely dependent):
General appearance: manner of dress:

G rooming/personal habits:

Prefer red time of personal care/bath:

Condition of hair/scalp:

Toileting assistance needs:

O ther:

14 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

SO C I A L I N T E RAC T I O NS A N D SE X U A L I TY
Erikson’s developmental task for client’s chronological age:

Client’s Self-Description:

Moral/E thical/Spiritual Influences:

Problems r/t illness/hospitalization:

H ealth C are Decision-making Process:

Client’s Role in F amily/ Structure of F amily:

Client’s Role in Community(wor k/clubs/activities):

Independence: Relationships with people/Support Systems:

Concerns/Stresses:

Religious A ffiliation:
Prefer red L anguage/Use of Interpreter:
Sexual Concerns:

Female:

L ast M ammogram: L ast Self-B reast E xam:

L ast Pap. Smear :
Live Births:
Genitalia:
Vaginal Discharge/Bleeding:
M ale:
L ast Prostate E xam: :
Genitalia:
Penis:
Penile Discharge/Bleeding:
Descended Testicles
Vasectomy Circumcision L ast Self-B reast E xam:

ST D:
O ther:

15 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

T E A C H I N G/L E ARN I N G
Dominant L anguage
L iterate (reading/writing):
E ducation level:
Cognitive limitations:
Client’s Stated Educational Needs:
Prefer red Method of Instruction:
C ulture/ethnicity: W here bor n:
If immigrant, how long in this country:
H ealth and illness beliefs/practices/customs:

H ealthcare decisions maker/spokesperson for client:

H ealth goals:

C lient expectations of this hospitalization:

A nticipated lifestyle changes resulting from hospitalization:

E vidence of failure to improve:

L ast complete physical examination:
Special healthcare concerns (e.g., impact of religious/cultural practices, healthcare decisions,
family involvement):

Familial risk factors (indicate relationship):

Diabetes:

Mental illness/depression: :
Other:
Non-prescribed D rugs/ O T C drugs:
D rug Dose T imes (circle last dose) Purpose

Other:

16 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

D ISC H ARG E PLA N CO NSI D E RA T I O NS

A nticipated date of discharge:
Information source:
Resources available:
Persons:
F inancial:
Community supports:
G roups:
Discharge Planning Needs: None

A reas that may require alteration/assistance:

- ocialization:

Physical layout of home (specify):

A nticipated changes in living situation after discharge:

Refer rals (date/source/services):

Oxygen Equipment:

O ther:

Student’s Data Collection Process:  (time taken, resources used, verification methods, circumstances

that may have influenced data collection: receptiveness of client, physical/psychological discomfort,
language/cultural barriers, environment of interview/exam, etc.):

17 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

HARTNELL COLLEGE
N R N-44.1 Portfolio: Part D: N R N-44.1 L aboratory Studies Tool

Instructions: Include all laboratory findings. Analyze the results as they relate to your client.

CBC Range Date(s) Results Pertinence to Client’s Current Status

WBC
RBC
Hematocrit
Hemoglobin
Platelet Count
ANC
Neutrophils %
Monocytes %
Eosinophils %
Basophils %
PT
PTT
INR
Sed. Rate
Other:

U.C H E M ISTRI ES Range Date(s) Results Pertinence to Client’s Current Status

Color
Clarity
Glucose
Bilirubin
Ketones
Sp. Gravity
pH
Protein
Urobiliogen
RBC
WBC
Epithelial Cells
Crystals
Bacteria
Mucus
Other:

18 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Instructions: Include all laboratory findings. Analyze the results as they relate to your client.
 

C H E M ISTRI ES Range Date(s) Results Pertinence to Clien t’s Current Status

Na+
K+
Cl-
Ca+
Mg+
BUN
Cr+
Serum CO2
Bilirubin
Protein
S.Albumin
AST (SGOT)
ALT (SGPT)
Alk. Phos.
Amylase
Lipase
FBS
RBS
HbA1c
Ammonia
LDH
BNP
CK/MB
Troponin
Myoglobin
LDH
HDL
C-R Protein
S. Toxicology
Other:

19 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Instructions: Include all laboratory findings. Analyze the results as they relate to your client.
 

ABG Range Date(s) Result(s) Pertinence to Client’s Current Status

pH
PO2
PCO2
HCO3
Base

O2 Sat

OTH ER Range Date(s) Result(s) Pertinence to Client’s Current Status

Peak/Trough
Blood
Cultures
Wound
Cultures
Specimens
Hemocult
O&P
C&S

20 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

HARTNELL COLLEGE
N R N-44.1 Portfolio: Part E : N R N-44.1 Diagnostic T ests Tool
Instructions: Identify all studies your client experienced during hospitalization. In the spaces
below describe the three most significant tests.
Upper Endoscopy UGI Lower Endoscopy Sigmoidoscopy
Colonoscopy Barium Enema Paracentesis ERCP
ECG Echocardiogram Bronchoscopy Thoracentesis
Venogram Arteriogram C. Catheterization
Chest Xray Ultrasound: CT Scan: MRI:
X Ray: Biopsy: PICC: Other:

Test:
Specific Reason:
Results
Preparatory care:

Post-procedure care:

Test:
Specific Reason:
Results:
Preparatory care:

Post-procedure care:

Test:
Specific Reason:
Results:
Preparatory care:

Post-procedure care:

21 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

HARTNELL COLLEGE
N R N-44.1 Portfolio: Part F : Nursing Plan of C are
N U RSI N G D I A G N OSIS: Medical Diagnosis:

D E F I N I T I O N:

D E F I N I T I O N:
C haracteristics

RELATED
F A C T O RS:

ST U D E N T In the space below, enter the subjective and objective data gathered during your
I NST R U C T I O NS: client assessment.
Subjective Data E ntry O bjective Data E ntry

A
S
S
E
S
S
M
E
N
T

To be sure your client diagnostic statement written below is accurate, review the
TIM E defining characteristics and related factors associated with the Nsg D x and see how
O U T! your client data match. Do you have an accurate match or are additional data
required, or does another Nsg D x need to be investigated?
D Nursing Diagnosis (specify)
I
A
G C lient Related to
N Diagnostic
O Statement
S
I
S

22 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

Desired O utcome The Client will:

and C lient C riteria:

T he desired outcome must meet criteria to be accurate. T he outcome must be specific,

realistic, measurable, and include a time frame for completion. Does the action verb
TIM E
P describe the client's behavior to be evaluated? C an the outcome be used in the
O U T!
L evaluation step of the nursing process to measure the client's response to the nursing
A interventions listed below?
N Interventions Rationale and References
N
I
N
G

E Do your interventions assist in achieving the desired outcome? Do your interventions

V address further monitoring of the client's response to your interventions and to the
TIM E
A achievement of the desired outcome? A re qualifiers: when, how, amount, time, and
O U T!
L frequency used? Is the focus of the action's verb on the nurse's actions and not on the
U client? Do your rationales provide sufficient reason and directions?
A W hat was your client's response to the interventions?
T
I W as the desired outcome achieved? Y es No If no, what revisions to either the desired
O outcome or interventions would you make?
N
Documentation Focus: Now that you have completed the evaluation, the next step is to document your
care and the client's response. Use the areas below to enter your progress note information.
D
Reassessment Data:
O
C
U
M
Interventions I mplemented:
E
N
T
A
C lient's Response:
T
I
O
N

Instructor’s Comments: 

23 
 
Name: _______________________________________ Client Initials:_____________ Rm#: _____________

HARTNELL COLLEGE
Part G : N R N-44.1 Reference L ist

Instructions: Include all nursing journals, medical-surgical textbooks and internet references
used for the assessment and management of clinical problems. Use APA formatting.

24