Eva Madison Vsim
NEW PROFESSIONAL TECHNICAL INSTITUTE
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME ______________________________________ DATE ______________
| Client Initials
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Culture/Ethnicity | Support system: |
| Unit 2 Room/Bed
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Religion | |
| Age Sex
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Language | |
| Weight Height
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Marital status N/A | |
| Current medical diagnosis
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Occupation: | Siblings |
| Health insurance : | Name of significant other/primary caregiver
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Current work status N/A
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Highest grade completed | Genogram: See attachment |
| Diagnostic procedures:
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| Surgical procedures:
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| Pathophysiology/psychopathology (List reference)
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| Psychopathology:
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| DEVELOPMENTAL STAGE/THEORIST | Vital signs/Frequency
_________________________________ Allergies/Side effects
_________________________________ Diet with rationale
_________________________________ Activity order
_________________________________ Limitations/prosthetic devices
_________________________________
_________________________________
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| Theorist:
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| BRIEF HEALTH HISTORY
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| PERTINENT LABORATORY DATA Lab Test #1
Rationale of abnormal results
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PERTINENT LABORATORY DATA Lab Test #2
Rationale of abnormal results _________________________
_________________________
_________________________ __
___________________________
___________________________
_________________________
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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 –
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INTRAVENOUS SOLUTION #2
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| MEDICATION NAME
TRADE/GENERIC |
DOSAGE ORDERED | TIMES ADMINISTERED | DOSE ROUTE | RATIONALE FOR ADMINISTERING | THERAPEUTIC RANGE FOR AGE/WEIGHT | NURSING IMPLICATIONS |
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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
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(Reference)
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| 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”
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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.”
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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.
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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 |
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| ASSESSMENT DATA
SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS | PLAN
OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS
(NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS | EVALUATION |
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