FLORIDA INTERNATIONAL UNIVERSITY Nicole Wertheim College of Nursing and Health Sciences CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME ______DATE ______
Social Determinants of Health: This header can be placed above occupation. It includes occupation, health insurance, current work status, etc. Unit Room/Bed Religion Support system
Age Sex Language
Weight Height BMI Marital status
Current medical diagnosis Occupation Siblings
Health insurance Name of significant other/primary caregiver
Current work status
Highest grade completed Genogram: Use back of page
Alcohol/Smoking/ Drug use/Sexual and Reproductive health
Diagnostic Data and Results:
Surgical procedures (current and past):
Past Health History:
4/2019
History of Present Illness:
Health Assessment
Physical Assessment:
HEENT:
NEURO:
CV:
RESP:
GI:
GU:
MUSCULOSKELETAL:
4/2019
INTEG:
ENDOCRINE:
HEMATOLOGIC:
Pathophysiology (please write in your own words) – Cite References in APA format Baseline and current vital signs/Frequency ______Allergies/Side effects ______Diet with rationale ______Activity order ______
4/2019
______Limitations/prosthetic devices ______
Include all Pertinent Laboratory Include all Pertinent Laboratory Include all Pertinent Laboratory Include all Pertinent Laboratory Data Results (normal and Data Results (normal and Data Results (normal and Data Results (normal and abnormal) abnormal) abnormal) abnormal) PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY DATA Lab Test #1 DATA Lab Test #2 DATA Lab Test #3 DATA Lab Test #4 ______
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Results______Results______Results______Results______
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______Rationale of abnormal results Rationale of abnormal results Rationale of abnormal results Rationale of abnormal results ______
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______INTRAVENOUS SOLUTION #1 INTRAVENOUS SOLUTION #2 Type ______Type ______
ML/HR ______gtts/min ______ML/HR ______gtts/min ______
Additives ______Additives ______
Rationale for solution Rationale for solution ______
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INTRAVENOUS SOLUTION #3 INTRAVENOUS SOLUTION #4 Type ______Type ______
ML/HR ______gtts/min ______ML/HR ______gtts/min ______
Additives ______Additives ______
Rationale for solution Rationale for solution ______
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4/2019
MEDICATION DOSE / TIMES RATIONALE FOR THERAPEUTIC NURSING IMPLICATIONS CITATIONS NAME ROUTE ADMINISTERED ADMINISTERING RANGE FOR Required Patient Education BRAND/GENERIC ORDERED AGE/WEIGHT If CLASSIFICATION Applicable
4/2019
MEDICATION DOSE / TIMES RATIONALE FOR THERAPEUTIC NURSING IMPLICATIONS CITATIONS NAME ROUTE ADMINISTERED ADMINISTERING RANGE FOR Required Patient Education BRAND/GENERIC ORDERED AGE/WEIGHT If CLASSIFICATION Applicable
4/2019
NURSING THEORIST CITE REFERENCES
NURSING DIAGNOSES - NANDA DESCRIBE RATIONALE FOR PRIORITY ORDER
LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY) UTILIZE THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE
4/2019
SAMPLE DIRECTION PAGE: Do not leave in when turning care plan into Faculty ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION SUBJECTIVE/ NANDA OUTCOME CRITERIA (NURSE CENTERED) INTERVENTIONS OBJECTIVE/ (CLIENT CENTERED) Cite References CONTRIBUTING Must flow from Diagnosis FACTORS and be individualized Include subjective Use a NANDA State the overall plan as Make the State the principle or Look at the outcome criteria. and objective diagnosis which has client centered, e.g.,: interventions nurse scientific rationale for components. three (3) parts: centered. the nursing State whether the client •"The client will..." intervention(s). achieved the outcome criteria, Assess •Part I: NANDA Indicate what the e.g., physiological, statement of nursing Relate the plan to the nurse will do to assist Include the reference psychosocial, problem nursing diagnosis: the client in achieving for the rationale. "The client gained 2 lbs within developmental, "Alternation in the outcome criteria, the past 7 days..." cultural and nutrition: Less than e.g., spiritual body requirements" •."have adequate NOTE: dimensions. nutritional intake" •The nurse will..." If the outcome criteria was not achieved or only partially •Subjective •Part 2: relating to a Indicate a measurable State frequency/time achieved, the nurse needs to go Document client's nursing etiology: outcome criteria by /amount so any nurse back to the beginning, e.g., the exact words "relating to including time can carry out the "assessment" and make relevant to the inadequate nutritional frame/amount/range: plan: revisions or changes as diagnosis. intake" necessary. 1) Document all food "I'm not hungry" •"as evidenced by..." intake for 3 days. •Part 3: manifested by •Objective the assessed signs 1) the ability to create a 2) Determine and Document data that and symptoms: balanced meal plan by make available is measurable, "manifested by low day (7). client's favorite foods specific, and body weight and by day 2. relevant to the emaciation." 2) gaining 1-2 lbs/wk nursing diagnosis. until FDA recommended 3) etc. weight is achieved. "Weight = 48 Kg" "Lack of (3) etc. subcutaneous fat"
4/2019
ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION SUBJECTIVE/ NANDA (North OUTCOME CRITERIA (CLIENT (NURSE CENTERED) INTERVENTIONS OBJECTIVE/ American Nursing CENTERED) Cite References CONTRIBUTING Diagnosis Must flow from Diagnosis and be FACTORS Association) individualized
4/2019
ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION SUBJECTIVE/ NANDA (North OUTCOME CRITERIA (CLIENT (NURSE CENTERED) INTERVENTIONS OBJECTIVE/ American Nursing CENTERED) Cite References (APA) CONTRIBUTING FACTORS Diagnosis Must flow from Diagnosis and be Association) individualized
4/2019
Discharge Plan / Patient Teaching
4/2019