During the clinical experience each student will be assigned a Major Care Plan (MCP). The MCP is a continuation of the Complete Health History completed in Physical Assessment. The MCP is a type written paper of all the information the student will collect pertaining to the assigned patient including; pt demographics (general information), physiologic & psychosocial subjective/ objective data, pt problem lists, pathophysiology, and Nursing Care Plan.
Forms needed for completing the MCP include:
- MCP Instructions (this form)
- Adult Medical/Surgical Assessment Tool
- Grading Criteria for MCP
- Nursing Assessment and Major Care Plan
*Forms are located on Blackboard and the “Black Cabinet” on your campus
Major care plans are due at the beginning of YOUR CLINICAL DAY two weeks after major care plan client is assigned by the clinical instructor. Points WILL be deducted and/or a clinical warning written for late MCP’s.
Students will be given an example of a complete MCP (located on Blackboard) to use as a guide.
Once the paper is turned in to the instructor, no revisions will be allowed to be made. The grade given on the first & only attempt will be the Final grade for this assignment.
Students must achieve a satisfactory in all areas of the MCP and achieve a final grade of at least 75%. Grades lower than 75% will result in an unsatisfactory clinical grade and thus failure from the N3118 CA-I course. Any student who plagiarizes the work of another will receive a 0% on the MCP and risks dismissal from the program of nursing.
Students need to bring the “Assessment Tool” form with them to each clinical day. Instructors will make MCP assignments based on student “readiness” & pt availability.
Make sure to collect ALL necessary information to complete the MCP the day it is assigned. Most pt’s are discharged before the next weeks clinical day, meaning the pt will not be there next week to ask questions.
Students are only to work on MCP when pt care is complete and may stay late if needed to gather the needed information.
**questions only after the instructor has left for the day, absolutely NO NURSING CARE will be given after that time.
- Do not limit your data collection to stated cues on your hand written paperwork, add descriptions.
- DO NOT use medical or nursing diagnosis in your problem lists.
- When you identify abnormal diagnostic tests, also identify the reason for the abnormal results.
- Diagnostics should include first & most recent or most severe abnormal & most recent—use dates! Look for those trends.
CLUSTERING & PRIORITIZING PROBLEMS
- Instructions: After assessing the client and documenting your assessment data on the Major Care Plan Assessment, you should have a list all of the problems which you identified and listed at the end of each system/mode. Place ALL problems into the cluster sheet, list problems r/t the same body system in each box (minimum-3 cluster boxes).
- **Remember, ALL problems identified in your assessment must be on this page. AND you have done this multiple times in physical assessment lab.
- PRIORITIZE these problems (according to Maslow) and list the problems in priority order on the Prioritized problem list sheet.
Example of problems:
Client becomes SOB when exerting himself
Client is dehydrated
Client has had no BM for 7 days
**Note: You should select the physiological nursing problem which you have given the highest priority to as the nursing diagnosis you will develop your nursing plan of care from.
PATHOPHYSIOLOGY & CARE PLAN
- Follow the guidelines on the MCP Grading Criteria to complete these sections. Use a Care Plan Questions sheet to make sure your care plan is written correctly.
- Make sure to follow the APA guidelines for the reference page and in-text citations. APA handouts are located in the “Black Cabinets” on your campus. MCP will need a title page and running head. References should be less than five years old and at least three references given
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