NURSING PROCESS WORKSHEET 2
\nStudent Name: ______________________________ Faculty Name: ________________ Date: _____________<\/p>\n
Weekly Nursing Process Worksheet
\nInstructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. This portion of your clinical day is of the utmost importance. It provides you with key teaching-learning opportunities for your clinical practice and focuses on your ability to demonstrate patient care management with specific disease states through the AAPIE: Assess Analyze Plan Implement Evaluate. In this manner, what is the major purpose for using Tanner’s model of clinical Judgement? involves recognizing that an issue exists (patient problem), analyzing information about issues (clinical data about a patient), evaluating information (reviewing assumptions & evidence), and making conclusions.
\nThese are quick notes and what should be assessed and what should be done throughout the shift. Expect to hone the skills of communication by focusing on the essentials of the care that was provided in handoff report and be able to \u201cgive report\u201d utilizing the AAPIE format. These will be discussed in clinical and in post conferences with the faculty. Upload to CANVAS After the conference.
\nDIRECTIONS
\nWhat needs to be done today. Completed Not Completed Comments
\nAssess the patient.
\nKnow the admitting diagnosis and hold (status if applicable)
\nRead the most recent physician and nursing notes.
\nHave the chart in hand or electronic chart open and be ready to report
\n\u2022\tallergies
\n\u2022\tmedication times scheduled
\n\u2022\tfluids
\n\u2022\tstat lab test results and pre-op or procedures (if pertinent)
\n\u2022\tcheck diagnostic studies and know the results
\nIDENTIFICATION DATA:<\/p>\n
Patient Initials: ________Patient Age: _______ Gender F M Allergies _________ Isolation: ___________
\nOther: __________ (special precaution\/risk\/ turn frequently)
\nSITUATION
\nI am reporting about: \tPatient initial: \tRoom #
\nThe I am reporting about:
\nProblem:
\n(Pt c\/o CP to L chest radiating to L arm x 1 hr )
\nSituation:
\n(Pt was shoveling show in the drive way, developed CP to L chest radiating to L arm x 1 hr ago, the CP was not relieved with NTG SL x 3, 911 was called by the wife)
\nIf this is a serious problem, identify what the code status is. \tCode\/DNR \tFull Code
\nIDENTIFYING DATA
\nWhy is the patient in the hospital:
\n(Provide brief statement which led to the patient\u2019s admission to hospital\/facility i.e need rehab post CVA)
\nSimilar to HPI<\/p>\n
Admitting Medical DX:
\n(i.e Pneumonia, MI, GI Bleed, Sepsis, UTI)
\nSurgery or Procedure
\n( For this admission)
\nBACKGROUND
\n\u2022\tBriefly state why the patient is in the hospital– give a synopsis of the treatment to date.<\/p>\n
\u2022 What is the admission plan?<\/p>\n
\u2022 Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none)<\/p>\n
\u2022 Relate the complaint given by the patient e.g., pain and anxiety level.<\/p>\n
\u2022 Relate the physical assessment pertinent to the problem, especially any changes.<\/p>\n
\u2022 Pay special attention to mental status, skin temperature and emotional state of the patient<\/p>\n
DM\/GI\/GERD\/GU\/ HTN\/ CVA\/ CKD\/CAD\/PVDCOPD\/Smoker\/ETOH\/Drug Abuse\/Dementia<\/p>\n
Psych: (any SI\/HI\/5150 hold) Living Situation: (homeless\/renting \/in a house \/ alone or with family)
\nASSESSMENT:
\nGive your hypothesis\/conclusions about the present situation. Words like “might be” or “could be.” are helpful.
\nA diagnosis is not necessary. (i.e., Patient\u2019s tongue swelling might be from side effects from ACE drugs)<\/p>\n
If the situation is unclear at least try to indicate what cues and or body system might be involved.<\/p>\n
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels)<\/p>\n
If appropriate, state the problem could be life threatening such as medication adverse effect.
\n(Pt is experiencing Red Man Syndrome from a severe reaction to Vancomycin infused too rapidly)<\/p>\n
ANALYSIS OF ASSESSMENT: use the template on the next page<\/p>\n
ANALYSIS OF ASSESSMENT:<\/p>\n
BP\tHR:\tRR:\tT: SaO2 Pain : \tHT (cm) \/ Wt (kg):
\nSystem \u2193
\nList the most important anticipated physical \/ assessment steps that you will complete for this patient. (Citations required).\tDescribe the WNL Findings
\n(ie. Lungs-CTAB\tOR\u2192\tOBJECTIVE (Abnormal – Bullet Points)
\nPotential Complications. Based on your research, to what complications would your patient be prone? List medical diagnoses- focus on complications that you can assess for or prevent. Include potential collaborative therapy\u2019s (Speech or Physical Therapy) psychosocial\/discharge planning complications (Citations required).
\nWhat is the cause of the patient\u2019s problem describe i.e., Respirations labored with intercostal retractions? Lung sounds diminished\tSUBJECTIVE (Abnormal – Bullet Points)
\nWhat is the cause of the patients problem describe i.e., Pt is having 8\/10 CP with exertion
\nNeuro\t\tOR\u2192
\nHEENT\t\tOR\u2192
\nCardio\t\tOR\u2192
\nResp\t\tOR\u2192
\nGI\t\tOR\u2192
\nGU\t\tOR\u2192
\nSkin\t\tOR\u2192
\nMobility\t\tOR\u2192
\nSafety\t\tOR\u2192
\nPsych-Soc\t\tOR\u2192
\nPain\t\tOR\u2192<\/p>\n
Diagnostic Data:
\nDiagnostic Exam (i.e Xray\/CT\/US)\tDate\tResults\tInterventions
\nEx Chest Xray\t11\/11\/21\tPleural Effusion\tChest Tube\/antibiotics<\/p>\n
MEDICATION LIST
\nMedications
\nGeneric \/ Trade
\nClass\/Rationale for the patient
\nDose\/Route\/ Time (Frequency)\tMechanism of action \tCommon side effects \tNursing considerations specific to this patient<\/p>\n
ABNORMAL ASSESSMENT FINDINGS:
\nAssessment: What are the identified abnormal findings:
\nList S&S= (signs & symptoms,
\ni.e., Abnormal Subjective and Objective Assessment Findings\/lab results, etc.)
\n1.
\nAnalysis: What is the cause of the patient\u2019s problem that must be prioritized at this time?
\nPt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain)
\n1.
\nPlanning (Patient goals focus on resolving the problem),
\nMust be SMART goals
\nby the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.)\t1.<\/p>\n
Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, auscultate, palpate, percuss};
\nVERBS
\nMonitor; Prepare, Administer; Collaborate w\/ specific multi-disciplinary team; & Teach, i.e., VERBS
\n1.
\nAssessment
\n(What was the outcome: Did you meet your desired goal? (Explain or Why not)
\nGoal: \u25a1 Met\t\t Goal: \u25a1 Not Met
\nGoal: \u25a1 Partially Met Goal: \u25a1 Unable to Assess<\/p>\n
What to Revise:<\/p>\n
1.<\/p>\n
Nursing Application Assessment
\nInclude activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN<\/p>\n
Management of Care: (Nursing treatments provided to patient to help disease or medical problem\/s)
\n______________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
Safety and Infection Control (Measures done to keep patient and you are safe, to prevent infection and worse condition)
\n______________________________________________________________________________________________________________________________________________________________________________________________________
\nBasic Care and Comfort (Nursing measures given to patient to keep clean and comfortable)
\n______________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
Definitions of Above<\/p>\n
Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.<\/p>\n
Related content includes but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality\/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals<\/p>\n
Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards.<\/p>\n
Related content includes but is not limited to: Accident\/Error \/Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety
\nReporting of Incident\/Event\/Irregular, Occurrence\/Variance, Safe Use of Equipment,
\nSecurity Plan, Standard Precautions\/Transmission- Based Precautions\/Surgical Asepsis, Use of Restraints\/Safety Devices
\nBasic Care and Comfort: providing comfort and Helpance in the performance of activities of daily living.<\/p>\n
Related content includes but is not limited to: Helpive devices, Elimination, Mobility\/Immobility, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest<\/p>\n
Student Daily Journal
\nPersonal goals for the day:<\/p>\n
Experience (specialty areas) and activities of the day:<\/p>\n
Thoughts about your experience today: (How did you meet your goal?)<\/p>\n
Your feelings about today: (How can you utilize your experience in the future?)<\/p>\n","protected":false},"excerpt":{"rendered":"
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