nursing process worksheet
jpulido90
NPWWorksheet.docxName:__________________________ Faculty Name:__________________________ Date:_____________
|
N101L: Nursing Process Worksheet |
||
|
Instructions: Each clinical day, the student will develop a nursing process outline for one patient of their choice. These will be discussed in clinical and in post-conferences with the faculty. Use the AAPIE Nursing Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the Patient Profile Database Worksheet and the Nursing Process Worksheet. Upload to CANVAS after the conference. |
||
|
DIRECTIONS |
||
|
What needs to be done: |
Completed |
If not, why? |
|
Receive Handoff Report |
|
|
|
Complete Head-to-Toe Assessment |
|
|
|
Review patient chart: · History and Physical · Progress Notes · Laboratory and Diagnostic Tests · Vital Signs · Medications |
|
|
|
IDENTIFICATION DATA |
||
|
Patient Initials: |
Age: |
Gender: |
|
Allergies: |
Isolation: |
Code Status: · Full Code · DNR · Modified: |
|
CHIEF COMPLAINT |
|
|
|
ADMITTING DIAGNOSIS |
|
|
|
HISTORY OF PRESENT ILLNESS (HPI) |
||
|
|
||
|
PERTINENT PAST MEDICAL HISTORY (PMH) |
||
|
|
|
Pathophysiology |
|
|
Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the patient. Use academic, evidence-based references to support each criteria. |
|
|
Pathophysiology of Admitting Diagnosis |
|
|
Signs & Symptoms |
|
|
Risk Factors |
|
|
Complications |
|
|
Describe the relationship between the pathophysiology and the patient’s current condition in your own words (does not need citation) |
|
|
CURRENT VITALS AND DATA |
|||
|
HR: |
RR: |
Pain: |
Height (cm): |
|
Temp: |
BP: |
SpO2:
|
Weight (kg): |
|
ANALYSIS OF ASSESSMENT CUES |
|||
|
Instructions: In the space below, enter both subjective & objective data for all body systems gathered during your client assessment. Identify the top 3 priority body systems containing the assessment cues with cited explanations in relation to the patient and admitting diagnosis. |
|||
|
Body System |
WNL or Abnormal |
List of Abnormal Assessment Cues |
Explanation of Abnormal Assessment Cues with evidence-based citations |
|
Neuro |
|
|
|
|
Cardio |
|
|
|
|
Resp |
|
|
|
|
GI |
|
|
|
|
GU |
|
|
|
|
Skin |
|
|
|
|
Mobility |
|
|
|
|
Safety |
|
|
|
|
Psych-Soc |
|
|
|
|
Pain |
|
|
|
|
ANALYSIS OF TOP 3 LABORATORY DATA/DIAGNOSTIC TESTS |
||||
|
Lab/Diagnostic Test |
Date |
Reference Range |
Result |
Why is this test necessary in relation to the patient’s admitting diagnosis? Use citations. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MEDICATION LIST |
||||||
|
Medication Generic / Trade |
Class - Pharmacological - Therapeutic |
Purpose (pertinent to patient) |
Dose/Route/Time (Frequency) |
Mechanism of Action |
Common Side Effects |
Nursing Considerations |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PRIORITY HYPOTHESIS/PROBLEM Using the pertinent abnormal cues, choose 1 priority hypothesis |
|
|
|
|
|
SMART GOAL Goal must be Specific, Measurable, Attainable, Realistic, and Timestamped. Start goal statement with, “Patient will... by...” |
|
|
|
|
|
IMPLEMENTATION For the identified priority hypothesis/problem, provide 4 independent interventions (1 must be a teaching intervention). All interventions must have a rationale supported with evidence-based citations. |
|
|
1. Rationale:
|
|
|
2. Rationale: |
|
|
3. Rationale:
|
|
|
4. Rationale: |
|
|
EVALUATION Select whether your goal was met, partially met, or not met. If goal was met, explain why. If goal was partially met or not met, must include revisions. |
|
|
· Goal Met |
Why the goal was met: |
|
· Goal Partially Met |
Revision(s): |
|
· Goal Not Met |
Revision(s): |
|
NURSING APPLICATION ASSESSMENT |
|
Instructions: Include activities throughout the day performed in relation to the following NCLEX content categories. See content category below for examples from the NCSBN. |
|
Management of Care Nursing treatments provided to patient to help disease or medical problem/s |
|
1. |
|
Safety and Infection Control Measures done to keep patient and you are safe, to prevent infection and worse condition |
|
2. |
|
Basic Care and Comfort Nursing measures given to patient to keep clean and comfortable |
|
3. |
DEFINITIONS OF ABOVE
Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.
Related content includes but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals
Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards.
Related content includes but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Managing Hazardous and Infectious Materials, Home Safety, Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices
Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living.
Related content includes but is not limited to: Assistive devices, Elimination, Mobility/Immobility, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest
|
STUDENT JOURNAL |
|
Personal goals for the day What clinical objectives did you focus on today? |
|
|
|
Experience (specialty areas) and activities of the day What new skills or procedures did you witness or participate/assist with? |
|
|
|
Thoughts about your experience today How did you meet your goal? Do you have any preconceived notions that changed? |
|
|
|
Your feelings about today How can you utilize your experience in the future? |
|
|
References
1
