Brittany Long Vsim

/in /by

NEW PROFESSIONAL TECHNICAL INSTITUTECLINICAL 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

 

 

 

 

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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

_________________________

 

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 PERTINENT LABORATORY DATA Lab Test #3

 

Results

 

 

___________________________

 

Rationale of abnormal results

___________________________

 

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 PERTINENT LABORATORY DATA Lab Test #4

 

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Results_____________________

 

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Rationale of abnormal results

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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

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