Posted: May 15th, 2023
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME ______________________________________ DATE ______________
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Client Initials
Culture/Ethnicity
Support system:
Unit 2 Room/Bed
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Religion
Age Sex
Language
Weight Height
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Marital status N/A
Current medical diagnosis
Occupation:
Siblings
Health insurance :
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Name of significant other/primary caregiver
Current work status N/A
Highest grade completed
Genogram: See attachment
Diagnostic procedures:
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Surgical procedures:
Pathophysiology/psychopathology (List reference)
Psychopathology:
DEVELOPMENTAL STAGE/THEORIST
Vital signs/Frequency
Can You Match My Writing Style?
Submit a sample of your writing, and we will mimic your style, tone, and vocabulary to make the paper feel authentically yours. This creates a seamless fit with your work. Our writers analyze writing patterns to ensure natural consistency with your previous submissions. Just upload your sample when ordering. Assignment writer experts replicate your voice to maintain consistency across all submissions.
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Allergies/Side effects
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Diet with rationale
What Is the Most Complex Topic You Have Handled?
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Activity order
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Limitations/prosthetic devices
Can You Provide a Detailed Outline?
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Theorist:
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
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PERTINENT LABORATORY DATA Lab Test #3
Results
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Rationale of abnormal results
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How Do You Ensure Rubric Compliance?
We analyze your rubric to align structure, content, and formatting, with editors double-checking to meet every requirement. This ensures your paper hits all the marks. Our systematic approach checks each rubric criterion individually for complete coverage. Upload your rubric for precise results. Assessment help includes meticulous rubric analysis to maximize your grade potential.
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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
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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
(Reference)
ASSESSMENT DATA
SUBJECTIVE/
OBJECTIVE
NURSING DIAGNOSIS
PLAN
What Is Your Quality Assurance Process?
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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"
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• 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:
Do You Offer Seasonal Discounts?
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" 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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