NEW PROFESSIONAL TECHNICAL INSTITUTE
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME ______________________________________ DATE ______________
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Client Initials |
Culture/Ethnicity |
Support system: |
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Unit 2 Room/Bed |
Religion |
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Age Sex |
Language |
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WeightHeight |
Marital status N/A |
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Current medical diagnosis |
Occupation: |
Siblings |
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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 |
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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 |
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 ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ |
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INTRAVENOUS SOLUTION #1 Type CC/HR gtts/min Additives: Rationale for solution – |
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 |
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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. |
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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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ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS |
PLAN OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS (NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS |
EVALUATION |
References
