NEW PROFESSIONAL TECHNICAL INSTITUTE
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME ______________________________________ DATE ______________
| Client Initials
|
Culture/Ethnicity | Support system: |
| Unit 2 Room/Bed
|
Religion | |
| Age Sex
|
Language | |
| Weight Height
|
Marital status N/A | |
| Current medical diagnosis
|
Occupation: | Siblings |
| Health insurance : | Name of significant other/primary caregiver
|
|
|
|
Current work status N/A
|
|
|
|
Highest grade completed | Genogram: See attachment |
| Diagnostic procedures:
|
||
| Surgical procedures:
|
||
| Pathophysiology/psychopathology (List reference)
|
||
| Psychopathology:
|
||
| DEVELOPMENTAL STAGE/THEORIST | Vital signs/Frequency
_________________________________ Allergies/Side effects
_________________________________ Diet with rationale
_________________________________ Activity order
_________________________________ Limitations/prosthetic devices
_________________________________
_________________________________
|
| Theorist:
|
|
| BRIEF HEALTH HISTORY
|
| PERTINENT LABORATORY DATA Lab Test #1
Rationale of abnormal results
|
PERTINENT LABORATORY DATA Lab Test #2
Rationale of abnormal results _________________________
_________________________
_________________________ __
___________________________
___________________________
_________________________
|
PERTINENT LABORATORY DATA Lab Test #3
Results
___________________________
Rationale of abnormal results ___________________________
___________________________
___________________________
___________________________
___________________________
___________________________ |
PERTINENT LABORATORY DATA Lab Test #4
___________________________
Results_____________________
___________________________
___________________________
___________________________
___________________________ Rationale of abnormal results ___________________________
___________________________
___________________________
___________________________
___________________________ |
| INTRAVENOUS SOLUTION #1
Type
CC/HR gtts/min
Additives:
Rationale for solution –
|
INTRAVENOUS SOLUTION #2
|
||
| MEDICATION NAME
TRADE/GENERIC |
DOSAGE ORDERED | TIMES ADMINISTERED | DOSE ROUTE | RATIONALE FOR ADMINISTERING | THERAPEUTIC RANGE FOR AGE/WEIGHT | NURSING IMPLICATIONS |
|
|
||||||
|
NURSING DIAGNOSES
LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY) |
DESCRIBE RATIONALE FOR PRIORITY ORDER
UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE
|
|||||
|
(Reference)
|
||||||
| ASSESSMENT DATA
SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS | PLAN
OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS
(NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS | EVALUATION |
| Include subjective and objective components.
Assess physiological, psychosocial, developmental, cultural and spiritual dimensions.
•Subjective Document client’s exact words relevant to the diagnosis.
“I’m not hungry”
•Objective Document data that is measurable, specific, and relevant to the nursing diagnosis.
“Weight = 48 Kg” “Lack of subcutaneous fat”
|
Use a NANDA diagnosis which has three (3) parts:
•Part I: NANDA statement of nursing problem “Alternation in nutrition: Less than body requirements”
•Part 2: relating to a nursing etiology: “relating to inadequate nutritional intake”
•Part 3: manifested by the assessed signs and symptoms: “manifested by low body weight and emaciation.”
|
State the overall plan as client centered, e.g.,:
•”The client will…”
Relate the plan to the nursing diagnosis:
•.”have adequate nutritional intake”
Indicate a measurable outcome criteria by including time frame/amount/range:
•”as evidenced by…”
1) the ability to create a balanced meal plan by day (7).
2) gaining 1-2 lbs/wk until FDA recommended weight is achieved.
(3) etc. |
Make the interventions nurse centered.
Indicate what the nurse will do to assist the client in achieving the outcome criteria, e.g.,
•The nurse will…”
State frequency/time /amount so any nurse can carry out the plan:
1) Document all food intake for 3 days.
2) Determine and make available client’s favorite foods by day 2.
3) etc.
|
State the principle or scientific rationale for the nursing intervention(s).
Include the reference for the rationale. |
Look at the outcome criteria.
State whether the client achieved the outcome criteria, e.g.,
“The client gained 2 lbs within the past 7 days…”
NOTE: If the outcome criteria was not achieved or only partially achieved, the nurse needs to go back to the beginning, e.g., the “assessment” and make revisions or changes as necessary. |
| ASSESSMENT DATA
SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS | PLAN
OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS
(NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS | EVALUATION |
|
|
|||||
| ASSESSMENT DATA
SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS | PLAN
OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS
(NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS | EVALUATION |
|
|
|
References
