CLINICALWORKSHEET:NURSINGPROCESSCAREPLAN

STUDENT NAME DATE

Client Initials	Culture/Ethnicity	Support system:
Unit 2 Room/Bed	Religion
Age Sex	Language
Weight Height Current medical diagnosis	Marital statusN/A
Weight Height Current medical diagnosis	Occupation:	Siblings Name of significant other/primary caregiver
	Health insurance :
	Current work status N/A
	Highest grade completed	Genogram:See attachment
Diagnostic procedures:
Surgicalprocedures:
Pathophysiology/psychopathology (List reference)
Psychopathology:

DEVELOPMENTALSTAGE/THEORIST

Vitalsigns/Frequency

Allergies/Sideeffects

Dietwithrationale Activity order

Limitations/prosthetic devices

Theorist:

BRIEFHEALTHHISTORY

PERTINENT LABORATORY	PERTINENT LABORATORY	PERTINENT LABORATORY	PERTINENTLABORATORYDATA
DATALabTest#1	DATALabTest#2	DATALabTest#3	LabTest#4
Rationale of abnormal results		Results
	Rationale of abnormal results		Results
		Rationale of abnormal results
			Rationale of abnormal results

INTRAVENOUSSOLUTION#1

Type

CC/HR gtts/min

Additives:

Rationale for solution –

INTRAVENOUSSOLUTION#2

MEDICATIONNAME

TRADE/GENERIC

DOSAGE ORDERE D

TIMES ADMINISTE RED

DOSE ROUTE

RATIONAL E FOR ADMINIST ERING

THERAPEUTIC RANGE FOR AGE/WEIGHT

NURSING IMPLICATIONS

NURSING DIAGNOSES

LISTIN PRIORITYORDER (BEGINNINGWITH #1 IN PRIORITY)

DESCRIBERATIONALEFORPRIORITYORDER

UTILIZEATHEORY(NEEDSTHEORY/NURSINGTHEORY) FOR RATIONALE

(Reference)

ASSESSMENTDATA SUBJECTIVE/ OBJECTIVE	NURSING DIAGNOSIS	PLAN OUTCOME CRITERIA(CLIENT CENTERED)	INTERVENTIONS (NURSE CENTERED)	RATIONALEFOR INTERVENTIONS	EVALUATION
Include subjective and objective components. Assess physiological, psychosocial, developmental, cultural andspiritualdimensions.	Use a NANDA diagnosiswhichhas three (3) parts: •Part I: NANDA statement of nursing problem “Alternation innutrition:Lessthanbody requirements” •Part2:relatingtoa nursing etiology: “relating toinadequatenutritional intake” •Part 3: manifested by the assessed signs and symptoms: “manifestedbylowbody weight andemaciation.”	State the overall plan asclientcentered, e.g.,: •”Theclient will…” Relatetheplantothe nursing diagnosis:	Make the interventionsnurse centered. Indicate what the nurse will do to assisttheclientin achieving the outcome criteria, e.g., • Thenurse will…” State frequency/time /amount so any nursecancarryout the plan: 1) Document allfoodintakefor3days. 2) Determineand make available client’s favorite foods by day 2. 3) etc.	State the principle or scientificrationale for the nursing intervention(s). Includethereference for the rationale.	Look at the outcome criteria. State whether the clientachievedthe outcome criteria, e.g.,
• Subjective Documentclient’sexact words relevant to the diagnosis.		•.”have adequatenutritionalintake“			“The client gained 2 lbswithinthepast7days…”
“I’m not hungry” • Objective Document data that is measurable,specific,and relevant to the nursing diagnosis. “Weight = 48 Kg” “Lackofsubcutaneous fat”		Indicateameasurable outcome criteria by including time frame/amount/range: •”asevidenced by…” 1)theabilitytocreate a balanced meal plan by day (7).			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.
		2)gaining1-2lbs/wkuntil FDArecommendedweightis achieved.
		(3) etc.

ASSESSMENTDATA SUBJECTIVE/ OBJECTIVE

NURSING DIAGNOSIS

PLAN OUTCOME

CRITERIA(CLIENT CENTERED)

INTERVENTIONS (NURSECENTERED)

RATIONALEFOR INTERVENTIONS

EVALUATION