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Posted: May 15th, 2023
CLINICAL 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
_________________________________
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
_________________________
_________________________
_________________________
__
___________________________
___________________________
_________________________
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 –
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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