CLINICAL APPLICATION OF THE NURSING PROCESS TOOL
Name _________________________
Course _________________________
Instructor _________________________
Client’s initials:__________ Actual Developmental Stage: _________________________
Gender: _____ Age: _____ Perceived Developmental Stage: _______________________
Reason for admission (if applicable) _____________________________________________
| Analysis (nsg.dx)
|
Expected Outcomes
(client goals) |
Implementation
(nursing interventions) |
Rationales
(Why? w/ references) |
Evaluation
(of goals) |
|
|
Scoring Code Key Student Name: _____________________
S – Satisfactory
NI – Needs Improvement
U – Unsatisfactory
Please submit this scoring criterion with the Care Plan.
| Area to be scored | Scoring code |
| 1. Analysis | |
| a. Determined basic needs of the client which are threatened | |
| b. Nursing Diagnosis are in priority order based on Maslow’s Hierarchy of Needs, and ABC’s (airway, breathing, circulation) | |
| All parts of the nursing diagnoses present and appropriate (Diagnosis statement, Related to (R/T) factors, patient specific – as evidenced by (AEB) subjective and objective (S / O) data) | |
| 2. Plan | |
| a. Goals are appropriate (time specific, measurable, focused, realistic) and related to the Nursing Diagnosis | |
| b. Measures to accomplish goal are appropriate | |
| 3. Rationale | |
| a. Uses scientific principles | |
| b. Reference sources are noted | |
| 4. Implementation | |
| a. Nursing actions carried out are specific and appropriate for goal attainment | |
| 5. Evaluation | |
| a. Describes clients responses to nursing interventions | |
| 6. Determines the extent to which goals have been met
(States goal attained, not attained or partially attained) |
|
COMMENTS:
