Posted: January 4th, 2023

NURSING PROCESS WORKSHEET 2

NURSING PROCESS WORKSHEET 2
Student Name: ______________________________ Faculty Name: ________________ Date: _____________

Weekly Nursing Process Worksheet
Instructions: 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.
These 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 “give report” utilizing the AAPIE format. These will be discussed in clinical and in post conferences with the faculty. Upload to CANVAS After the conference.
DIRECTIONS
What needs to be done today. Completed Not Completed Comments
Assess the patient.
Know the admitting diagnosis and hold (status if applicable)
Read the most recent physician and nursing notes.
Have the chart in hand or electronic chart open and be ready to report
• allergies
• medication times scheduled
• fluids
• stat lab test results and pre-op or procedures (if pertinent)
• check diagnostic studies and know the results
IDENTIFICATION DATA:

Patient Initials: ________Patient Age: _______ Gender F M Allergies _________ Isolation: ___________
Other: __________ (special precaution/risk/ turn frequently)
SITUATION
I am reporting about: Patient initial: Room #
The I am reporting about:
Problem:
(Pt c/o CP to L chest radiating to L arm x 1 hr )
Situation:
(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)
If this is a serious problem, identify what the code status is. Code/DNR Full Code
IDENTIFYING DATA
Why is the patient in the hospital:
(Provide brief statement which led to the patient’s admission to hospital/facility i.e need rehab post CVA)
Similar to HPI

Admitting Medical DX:
(i.e Pneumonia, MI, GI Bleed, Sepsis, UTI)
Surgery or Procedure
( For this admission)
BACKGROUND
• Briefly state why the patient is in the hospital– give a synopsis of the treatment to date.

• What is the admission plan?

• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none)

• Relate the complaint given by the patient e.g., pain and anxiety level.

• Relate the physical assessment pertinent to the problem, especially any changes.

• Pay special attention to mental status, skin temperature and emotional state of the patient

DM/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia

Psych: (any SI/HI/5150 hold) Living Situation: (homeless/renting /in a house / alone or with family)
ASSESSMENT:
Give your hypothesis/conclusions about the present situation. Words like “might be” or “could be.” are helpful.
A diagnosis is not necessary. (i.e., Patient’s tongue swelling might be from side effects from ACE drugs)

If the situation is unclear at least try to indicate what cues and or body system might be involved.

State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels)

If appropriate, state the problem could be life threatening such as medication adverse effect.
(Pt is experiencing Red Man Syndrome from a severe reaction to Vancomycin infused too rapidly)

ANALYSIS OF ASSESSMENT: use the template on the next page

ANALYSIS OF ASSESSMENT:

BP HR: RR: T: SaO2 Pain : HT (cm) / Wt (kg):
System ↓
List the most important anticipated physical / assessment steps that you will complete for this patient. (Citations required). Describe the WNL Findings
(ie. Lungs-CTAB OR→ OBJECTIVE (Abnormal – Bullet Points)
Potential 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’s (Speech or Physical Therapy) psychosocial/discharge planning complications (Citations required).
What is the cause of the patient’s problem describe i.e., Respirations labored with intercostal retractions? Lung sounds diminished SUBJECTIVE (Abnormal – Bullet Points)
What is the cause of the patients problem describe i.e., Pt is having 8/10 CP with exertion
Neuro OR→
HEENT OR→
Cardio OR→
Resp OR→
GI OR→
GU OR→
Skin OR→
Mobility OR→
Safety OR→
Psych-Soc OR→
Pain OR→

Diagnostic Data:
Diagnostic Exam (i.e Xray/CT/US) Date Results Interventions
Ex Chest Xray 11/11/21 Pleural Effusion Chest Tube/antibiotics

MEDICATION LIST
Medications
Generic / Trade
Class/Rationale for the patient
Dose/Route/ Time (Frequency) Mechanism of action Common side effects Nursing considerations specific to this patient

ABNORMAL ASSESSMENT FINDINGS:
Assessment: What are the identified abnormal findings:
List S&S= (signs & symptoms,
i.e., Abnormal Subjective and Objective Assessment Findings/lab results, etc.)
1.
Analysis: What is the cause of the patient’s problem that must be prioritized at this time?
Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain)
1.
Planning (Patient goals focus on resolving the problem),
Must be SMART goals
by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.) 1.

Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, auscultate, palpate, percuss};
VERBS
Monitor; Prepare, Administer; Collaborate w/ specific multi-disciplinary team; & Teach, i.e., VERBS
1.
Evaluation
(What was the outcome: Did you meet your desired goal? (Explain or Why not)
Goal: □ Met Goal: □ Not Met
Goal: □ Partially Met Goal: □ Unable to Assess

What to Revise:

1.

Nursing Application Assessment
Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN

Management of Care: (Nursing treatments provided to patient to help disease or medical problem/s)
______________________________________________________________________________________________________________________________________________________________________________________________________

Safety and Infection Control (Measures done to keep patient and you are safe, to prevent infection and worse condition)
______________________________________________________________________________________________________________________________________________________________________________________________________
Basic Care and Comfort (Nursing measures given to patient to keep clean and comfortable)
______________________________________________________________________________________________________________________________________________________________________________________________________

Definitions of Above

Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.

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

Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards.

Related content includes but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety
Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment,
Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices
Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living.

Related content includes but is not limited to: Assistive devices, Elimination, Mobility/Immobility, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest

Student Daily Journal
Personal goals for the day:

Experience (specialty areas) and activities of the day:

Thoughts about your experience today: (How did you meet your goal?)

Your feelings about today: (How can you utilize your experience in the future?)