assistance

Student Name: ______________________________ Faculty Name: ________________ Date: _____________

Weekly Nursing Process Worksheet Instructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. This portion of your clinical day is of the

utmost importance. It provides you with key teaching-learning opportunities for your clinical practice and focuses on your ability to demonstrate

patient care management with specific disease states through the AAPIE: Assess Analyze Plan Implement Evaluate. In this manner, what is the major

purpose for using Tanner's model of clinical Judgement? involves recognizing that an issue exists (patient problem), analyzing information about issues

(clinical data about a patient), evaluating information (reviewing assumptions & evidence), and making conclusions.

These are quick notes and what should be assessed and what should be done throughout the shift. Expect to hone the skills of communication by

focusing on the essentials of the care that was provided in handoff report and be able to “give report” utilizing the AAPIE format. These will be discussed in

clinical and in post conferences with the faculty. Upload to CANVAS After the conference.

DIRECTIONS

What needs to be done today. Completed Not Completed Comments Assess the patient.

Know the admitting diagnosis and hold status

Read the most recent physician and nursing notes.

Have the chart in hand or electronic chart open and be ready to report • allergies

• medication times scheduled

• fluids,

• stat lab test results and pre-op or procedures (if pertinent)

IDENTIFICATION DATA:

Patient Initials: ________Patient Age: _______ Gender F M Allergies _________ Isolation: ___________

Other: __________

SITUATION

I am reporting about: Patient initial: Room #

The problem and situation I am reporting about is:

Problem:

Situation:

If this is a serious problem, identify what the code status is. Code/DNR Full Code

IDENTIFYING DATA

Why is the patient in the hospital: (Provide brief statement which led to the patient’s admission to hospital/facility i.e., need rehab post CVA)?

Admitting DX: _____________________________________________Surgery: ____________________________________

BACKGROUND

• Briefly state why the patient is in the hospital give a synopsis of the treatment to date.

• What is the admission plan?

• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none)

• Relate the complaint given by the patient e.g., pain and anxiety level.

• Relate the physical assessment pertinent to the problem, especially any changes.

• Pay special attention to mental status, skin temperature and emotional state of the patient

PERTINENT HISTORY: (include pertinent history)

DM/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia

Psych: __________________________ Living Situation: __________________________

ASSESSMENT:

Give your conclusions about the present situation. Words like "might be" or "could be."

are helpful. A diagnosis is not necessary. (i.e., Patient’s tongue swelling might be from side effects from ACE drugs)

If the situation is unclear at least try to indicate what body system might be involved.

State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels)

If appropriate, state the problem could be life threatening such as medication adverse effect.

(Pt is experiencing Red Man Syndrome from a severe reaction to Vancomycin infused too rapidly)

ANALYSIS OF ASSESSMENT: use the template on the next page

ANALYSIS OF ASSESSMENT:

Student Instructions: In the space below, enter the subjective and objective data gathered during your client assessment.

P HR RR T: SaO2 Assess Pain: (cm) ____________ / (kg): __________

System ↓

List the most

important

anticipated physical

/ assessment steps

that you will

complete for this

patient. (Citations

required).

Describe the

WNL

Findings

OR→ OBJECTIVE (Abnormal - Bullet Points)

Potential Complications. Based on your

research, to what complications would

your patient be prone? List medical

diagnoses- focus on complications that

you can assess for or prevent. Include

potential collaborative therapy’s (Speech

or Physical Therapy)

SUBJECTIVE (Abnormal - Bullet Points)

What is the cause of the patients problem

describing i.e., Pt is having SOB 8/10 with

exertion

Dr Debra Wallace 12/14/2021 Med/Surg

psychosocial/discharge planning

complications (Citations required).

What is the cause of the patients problem

describing i.e., Respirations labored with

intercostal retractions? Lung sounds

diminished

Neuro OR→

Cardio OR→

Resp OR→

GI OR→

GU OR→

Skin OR→

Mobility OR→

Safety OR→

Psych-Soc OR→

Pain OR→

Need Analysis of Laboratory Data/Treatments: ____________________________

What would you anticipate as a result of this specific test result?

Diagnostic Data:

Exam Date Results Interventions

MEDICATION LIST

Medications

Generic / Trade Class/Rationale for the

patient

Dose/Route/ Time

(Frequency)

Mechanism of

action

Common side

effects

Nursing considerations specific to this

patient

TIME OUT!!! Student instructions: To be sure your critical thinking statement written below is accurate, you need to

review the defining characteristics and related factors associated with and see how your patient data match. Do you

have an accurate match or are additional data required, or does another cue from abnormal assessment findings need

to be investigated?

ABNORMAL ASSESSMENT FINDINGS: Recognize Cues Obtain information from various sources (e.g., the environment, the pt., the family, another nurse, EHR) in different

formats (e.g., visual observation, audio perception, lab results, text description, etc.). TIME OUT!!! Do you have an

accurate match or are additional data required, or does another cue from abnormal assessment findings need to be

investigated?

Assessment: What are the identified abnormal findings:

• List S&S= (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.) ______________________________________________________________________________________

Analysis Cues Interprets cues from their existing knowledge base and nursing perspective, evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organize cues in the mental representation of the scenario (e.g., organize cues in clusters), and then develops a group of probable client needs/concerns and problems. Prioritize Hypotheses Evaluates the hypotheses generated previously in various dimensions (e.g., urgency, likelihood, risk/difficulty/time/cost of providing care to that hypothesis, etc.), and organize them into an ordered list where the priority hypotheses (i.e., client needs/concerns/problems) are on the top. Analysis/Hypothesis: What is the cause of the patients problem that must be prioritized at this time?

• Evaluate the Hypothesis = (Signs and symptoms, i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.) _________________________________________________________________________________________

Planning (Patient goals focus on resolving the problem), Must be SMART goals Generate Solutions Develops a list of actions to address the priority hypothesis. The student nurse then selects the appropriate action from the list and carries out the action. TIME OUT!! The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic, measurable, and include a time frame for completion. Does the action verb describe the patient’s behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the patient’s response to the nursing interventions listed below?

• Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain)

__________________________________________________________________________

• by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.)

____________________________________________________________________________________

Implementation (Specific nursing interventions that were performed during your shift): Take Action Sorts the hypotheses (probable client needs, concerns, problems) in order (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority. Must contain the following: Assess {observe, auscultate, palpate, percuss}; Monitor; Prepare, administer; Collaborate w/

specific multi-disciplinary team; & teach, i.e., VERBS

1._____________________________________________________________________________________

2.____________________________________________________________________________________

3._____________________________________________________________________________________

4. ____________________________________________________________________________________

Evaluation (What was the outcome: Did you meet your desired goal?) TIME OUT!! Re-Assess the Patient: Do your interventions address further monitoring of the patient’s response to your interventions and to the achievement of the desired outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the action’s verb on the nurse Goal; Met or Not met or partially met and how to revise.)

Goal: □ Met Goal: □ Not Met Goal: □ Partially Met Goal: □ Unable to Assess

How to Revise: __________________________________________________________________________

Nursing Application Assessment

Include activities throughout the day performed in relation to the following NCLEX content categories. See content

category examples below as cited by NCSBN

Management of Care: (Nursing treatments provided to patient to help disease or medical problem/s)

___________________________________________________________________________________________________

Safety and Infection Control (Measures done to keep patient and you are safe, to prevent infection and worse condition)

___________________________________________________________________________________________________

Basic Care and Comfort (Nursing measures given to patient to keep clean and comfortable)

___________________________________________________________________________________________________

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:

Experience (specialty areas) and activities of the day:

Thoughts about your experience today: (How did you meet your goal?)

Your feelings about today: (How can you utilize your experience in the future?)