Nursing B26
Clinic Forms
3rd Semester RN
MEDICAL/SURGICAL ROTATION
NURSING PROCESS
CARE PLAN
PACKET
Clinical Site Instructor:
RN STUDENT:
NURSING PROCESS GRADE SHEET Student: ______
Grading Criteria / Possible Points / Points Earned / CommentsPart I: Demographics
· Face sheet, MD orders, ADM dx secondary dx, PMH, Substance abuse, allergies, HPI / 3 / All active orders must be here. Not just the ones written the day you look at the chart.
Physical Assessment
Add a narrative to the nurses notes / 10 / 5
5 / Focus on increasing evaluating the students ability to perform a physical assessment – and understanding what it means.
Refer the student to the text for each diagnosis/disease process.
Part II : Pathophysiology Concept Maps
Work up 2: (4 points)
Definitions, etiology, chronicity, prognosis, risk factors, signs and symptoms, lab and diagnostic studies, medical and nursing interventions, and potential complications.
Patient Specific (10 points)
References (2 points)
Inter-related (8 points)
Maximum 2 pages per map / 20
Part III: Medications / Tactis
· Client specific
· List of all medications
· Purpose of medication / 10 / Identify what medications are/is most important for the top 2 diagnosis.
5 medications pertinent to disease process in priority order. Students must list all meds taken on the general sheet including prn’s but a TACTIS on 5 meds.
Part IV: Labs / Diagnostics
· Client specific
· Anticipate MD Response
· Anticipated nursing
· Highlight abnormal values document possible causes / 12 / 3
3
3
3 / All labs.
Part V: Plan of Care
Nursing Diagnosis (____ points / Dx)
· Covers bio-psycho-socio needs as related to the patient
· Nursing Diagnosis are prioritized appropriately
· Nursing Diagnosis are based on Nanda Format (complete)
· Nursing Diagnosis reflect defining characteristics
Goals (1 pt/goal)
· Patient specific
· Realistic and measurable
· States a time frame
· Relates to nursing diagnosis and nursing orders
Interventions and Rationales
· Appropriate
· Realistic
· Minimum of 4 per Dx
· Prioritized
· Sources cited
Evaluation
· Statement of met/unmet (2pt)
· Describe progress towards goals (2 pts)
· Evaluate effectiveness of nursing interventions
· List suggested revisions / 40
5
5
20
10 / Pick 4 diagnosis and write out 2 diagnosis in long form. Prioritize the 4 dx in order and write out the 2.
Include meds as an intervention and specifically how your interventions are different than an LVN or CNA.
Level Outcome Summary Sheet
What if any, did you expect to see in your client that you did not? / 3 / For each mgr of care, prov of care and mem of prof. what did you do specifically for this patient.
Final Score
Please see comments throughout paper
A total of 2 points may be deducted for:
Presentation, grammar and format / 2
PART I: DEMOGRAPHICS & CURRENT PHYSICIAN ORDERS
(kgs) / Age / Gender / Immunization / Date / Advanced Directive / Code Status / Admit
Date / Date(s) of Care
□ Influenza
□ Pneumovax
□ Tetanus / □ Yes
□ No / □Full
□Directed
□ CPR
□ Drugs
□ Ventilator
□ Defibrillate
□DNR
Admitting Diagnosis
Secondary Diagnoses (Acquired during hospital stay, subsequent to admitting diagnosis)
History of present Illness (Sequence of events beginning from admission expanding to day of care)
Recent Surgical Procedure(s) / Date(s) (Within in the past five years, or relevant to current diagnoses)
Past Medical History
Substance Use (Include type, frequency, and duration)
Tobacco □ Yes □ No
Alcohol □ Yes □ No
Elicit drugs □ Yes □ No
OTC □ Yes □ No
Allergies / Reactions
Ethnicity / Religious Preference / Marital Status / Family Structure / Occupation
CURRENT PHYSICIAN Orders
PART II: PATHOPHYSIOLOGY CONCEPT MAP
Interrelation
(write out the correlation between your patho’s. How does one relate to another)PART III: T A C T I S FACESHEET
Complete a medication list for ALL drugs, routine and PRN, which includes drug, dose and frequency.
□Review medication reconciliation form
□Which medications were taken at home prior to hospitalization?
Routine Medications
PO
IV
Other
PRN Medications
PO
IV
Other
PART III: PRESCRIBED MEDICATIONS: T A C T I S
MEDICATIONS – TRADE / GENERIC______
DOSE / ROUTE / FREQUENCY ______
PHARMACOLOGICAL CLASSIFICATION______
Why is THIS client receiving this drug? ______
______
______
Is this a home medication?
TTherapeutic classification /
A
Action /C
Contraindications
(list only if contraindicated for this client)
/T
Toxic /Side Effects(Most serious & frequent) /
I
Interventions
(Include nsg intervention, labs, parameters for this med) /S
Safety(Include MSI *& MSD*for all
IV Meds)
Safe dose: □Yes □ No
Crush med: □Yes □ No
*All meds being titrated (i.e., heparin) state appropriate lab results related to medication administration. Allergies: ______
** MSI – minimum safe infusion; MSD – minimum safe dilution Reference: ______
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
Test
/ Reference Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
WBCRBCs
Hgb
Hct
MCV
MCH
MCHC
RDW
Retic.
Platelet
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Reference Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
SodiumChloride
Potassium
CO2
BUN
Creatinine
Glucose
Magnesium
Calcium
Phosphorus
INR
PT
PTT
On anticoag. ®
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Reference Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
ASTALT
Acid Phosphatase
Ammonia
LDH
Alk. Phos.
Total Bilirubin
Cholesterol
Uric acid
Total protein
Albumin
Globulin
Amylase
Lipase
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
pH
pCO2
pO2
BE
O2 Sat
HCO 3
Interpretation
*Oxygen
(if not on vent) / Device
% FiO2 / Device
% FiO2 / Device
% FiO2 / Device
% FiO2
Action taken to correct balance?
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
DigoxinTheophylline l
Dilantin
Antibiotics
Source: / Range / Date
Baseline / Date / Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
Color
Appearance
Spec.gravity
Protein
Glucose
Ketones
Nitrites
Leukoesterase
Bacteria
Blood
Other
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Body Part Involved / Reason THIS test performed on THIS client / DateResult
/ DateResult / Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
X rays
X rays
X rays
MRI / CT
(circle one)
Nuclear Scan
Other
PART IV: ADULT LABORATORY / DIAGNOSTIC TOOL
ADMIT DATE ______DATE OF CARE______CLIENT’S ROOM #_____ REFERENCE______
Test
/ Range / DateBaseline
/ Date / Date /Identify ¯/ Significance / Trends / Nursing Interventions /Anticipated MD response
PART V: NURSING DIAGNOSES: PRIORITIES AND RATIONALES
NANDA Statement in Order of Priority / Rationale for Priority1.
2.
3.
4.
PART V: PLAN OF CARE
Priority # / NANDADiagnostic Statement / Goals / Nursing Interventions / Rationale / Evaluation
NDx: (problem)
R/T: (etiology / factor)
AEB: (s/sx; defining characteristics, lab,
diagnostic data) / (list measurable outcomes)
LTG: Client will:
STG: Client will: / 1.
2.
3.
4. / 1.
2.
3.
4. / Goals accomplished?
STG ? □ Yes □ No
LTG ? □ Yes □ No
Progress to LTG?
Effectiveness of nursing interventions?
Suggested revisions?
PART V: PLAN OF CARE
Priority # / NANDADiagnostic Statement / Goals / Nursing Interventions / Rationale / Evaluation
NDx: (problem)
R/T: (etiology / factor)
AEB: (s/sx; defining characteristics, lab,
diagnostic data) / (list measurable outcomes)
LTG: Client will:
STG: Client will: / 1.
2.
3.
4. / 1.
2.
3.
4. / Goals accomplished?
STG ? □ Yes □ No
LTG ? □ Yes □ No
Progress to LTG?
Effectiveness of nursing interventions?
Suggested revisions?
Part VI: Summary Statement
Once your process is complete, review each section in terms of specific Level Outcomes including the RN’s role as a Provider of Care, Manager of Care, and Member of the Nursing Profession. Write a short summary statement on how you have operationalized these concepts meeting each of the three roles.
BIBLIOGRAPHY
PHYSICAL ASSESSMENT DATA Client Initials: Date;BP
BP / TPR
TPR / Height ______Weight ______
Review of SYSTEMS
NEUROLOGICAL
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
SKIN
PSYCHOSOCIAL
PAIN
PHYSICAL ASSESSMENT DATA Client Initials: Date;
BP
BP / TPR
TPR / Height ______Weight ______
Review of SYSTEMS
NEUROLOGICAL
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
SKIN
PSYCHOSOCIAL
PAIN