What This Document Is
This is a Clinical Plan of Care paperwork form used by students in the Fundamentals of Nursing (NURS B260) course at Indiana University - Purdue University Indianapolis (IUPUI). It’s designed for students to comprehensively document patient assessments and care planning during a clinical rotation, specifically dated February 25, 2022.
Why This Document Matters
This form is essential for nursing students completing clinical hours. It serves as a structured tool to gather patient data, analyze findings, and formulate a plan of care under the guidance of a clinical instructor. Successful completion and submission of this paperwork are likely a requirement for course credit. It’s used *during* a clinical shift and submitted *after* for evaluation.
Common Limitations or Challenges
This document is a *template* for data collection and planning. It does not provide nursing diagnoses, interventions, or evaluations – those are the student’s responsibility based on their assessment. It also requires external knowledge of APA formatting for rationales and citations.
What This Document Provides
The full document includes: sections for student identification and clinical date, detailed instructions for completion, a one-page data sheet (“brain”) for comprehensive patient assessment, tables for organized assessment findings (general inspection, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, integumentary), space for documenting IV access, medications, intake/output, and a reference card for bedside assessment basics. It *does not* include completed patient data, rationales, or a reference list – those are to be added by the student.
