Patient/Client Nursing Process

University of ColoradoDenverCollege of Nursing

Student Name:Date:Patient Initials:

Age: Gender: Unit: Date of Admission to Hospital: Date(s) you provided care for the patient/client:

Allergies and Reactions:

Code Status:Isolation Precautions: Falls Precautions:

.OSA (Obstructive Sleep Apnea): .MDRO (Multiple Drug Resistant Organisms):

Medical Diagnosis(List primary and secondary, if present):

#1______#2______

History

  1. History of presenting illness (what brought them in) and course of present hospitalization (what has happened since they have

been hospitalized) – include dates if pertinent (surgeries/medical procedures):

  1. Past Medical/Sugical History (Prior illnesses/hospitalizations, chronic illnesses, surgeries – include dates as able):
  1. Social History (Consider family factors, support person(s), spiritual needs, ESL, economic status):

Marital Status:Occupation:Religion:

Cultural Influences:

Tobacco/Alcohol/Drug Use:

Health promotion activities (diet, exercise, sleep/rest patterns, coping strategies/stress reduction, medical/dental health usage):

Economic factors (insurance, income sources, concerns related income and health):

Age Specific Developmental Needs:

Pathophysiology Reference your source (Author, yr, page#s)Use reverse side of this page if additional space needed for Pathophysiology and Etiology

  1. Briefly define the pathophysiology of the major disease process (what is the malfunction).
  1. Etiology
  2. How does it develop (what is the cause?).
  1. Risk Factors and Signs/Symptoms

1.)Relate the above to your patient.

  1. Regarding surgical patients: Briefly describe the surgical procedure.
  1. List of 3 potential post op complications and the signs and symptoms of these complications.

1.)

2.)

3.)

Anticipatory Nursing Diagnosis List 3-4 potential/anticipatory Nursing Diagnosis (without R/T), based on data mining and patho.

1.)

2.)

3.)

4.)

OBJECTIVE DATA – Select and include an Organizational Tool. Fill it out as much as you can, i.e. med. schedule, anticipated cares/ADLs, location of drains and catheters, questions you need answered, etc.

OBJECTIVE DATA (FROM ASSESSMENT of Patient/Client)

Physical Assessment Data

VITAL SIGNS:

HT: WT: Intake/Output:

Neuro / Sensory (Level-of-consciousness, orientation, pupils, motor/sensory-- extremity strengths/numbness/tingling verbal expression, mood/affect, vision, hearing, smell, taste and cranial nerves, if appropriate):

Pain (Type of Pain Assessment tool used – WILDA, PABS, Faces, FLACC) Pain Assessment Score; Pain characteristics: location, type, duration; aggravating and alleviating factors Interventions; Reassessment):

Cardiovascular (Heart sounds, rhythm, pulses, capillary refill, JVD, edema):

Respiratory (Breathing pattern, breath sounds, cough, secretions, pulse ox, O2 therapy, respiratory treatments):

Gastrointestinal (Current diet, nausea & vomiting, abdominal assessment, bowel sounds, flatus, bowel pattern/characteristics, last BM):

Genitourinary (Continent/incontinent, foley, urine characteristics; LMP, pre/post menopausal, prostrate problems, discharge):

Musculoskeletal System (Physical mobility, range-of-motion, gait, traction, amputation, complete functional ability table):

Integumentary System (Temp, color, moisture, turgor, skin breakdown, wounds, drains/tubes, dressings, drainage; complete Blank Body diagram):

Intravenous Therapy (Type(s) of IV device(s), location, site/assessment, IV fluid type(s) and rate(s); complete Blank Body diagram):

Type of Continuous Intravenous Infusion(s):

Functional Ability:

Self Care Ability: 0=Independent1=Assistive Device 2=Assistance from others 3=Assistance from person and equipment4=Dependent/unable

0 1 2 3 4

Eating/Drinking
Bathing
Dressing/Grooming
Toileting
Bed Mobility
Transferring
Ambulating

Assistive Devices: ____None____Crutches____Bedside Commode____Walker____Cane____WC____Splint/Brace

Consultations: ______Physical Therapy ______Occupational Therapy ______Speech Therapy

If the patient is receiving care from PT, OT and/or ST (above), what is the most recent identified patient/client care needs and/or goals:

1.

2.

3.

4.

5.

6.

7.

8.

PATIENT/FAMILY TEACHING NEEDS (Plan of care, medications, treatments, therapies, assistive devices, self-care):

DISCHARGE PLANNING (If not observed/participant, approach from a theoretical perspective. Examples: 1) Evaluate:

a) Adequate support system in place? i.e. discharge to home; home w/home health care; transitional care; rehab; skilled nursingfacility; hospice? b) Adequate financial resources? c) Home safety 2) Teaching: r/t a) medications, b) S/Sx’s to report to physician, c) wound care, d) therapies/self-cares, e) health promotion/illness prevention, f) assistive devices, g) activity limitations/restrictions, h) diet, i) follow-up with physician(s):

Lines, Drains, Airway, Wounds and Wires/Tubes

Instructions:

Part I: Assess patient for the following items and use the diagrams below to draw an arrow to location and label:

  1. Intravenous lines6. Wound, pressure ulcers, and/or incisions
  2. Drains7. Urinary and/or bowel diversions
  3. Chest tube8. Feeding tubes
  4. Telemetry leads9. DVT compression device
  5. Airway and/or oxygen tubing10. Other ______

Part II: Describe in a short paragraph the purpose and safety considerations of each identifieditem.

Legal/Ethical Issues:

Identify 1-2 legal and/or ethical issues associated with this client/patient, family/significant other, nursing care, or other issues that directly pertain to this patient’s care.

Researchable Area:

Reference a minimum of one recent (within the last 5 years) nursing research article (from a nursing journal) which either relates to your client/patient’s condition, related nursing interventions/care, research findings, or new procedures/treatment related to your client/patient. Include a copy of each article.

NURSING DIAGNOSES

Please list all Nursing Diagnoses that apply to your patient and the assessment data that lead you to identifying each diagnosis (ex. Pain r/t surgical intervention AEB patient’s self-reported pain of 7 utilizing the 0-10 pain scale; facial grimacing). Prioritize the top 3 Nursing Diagnoses and develop a Care Plan based on the 3 priority diagnoses.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

MEDICATIONS (USE THIS FORMAT FOR SCHEDULED AND PRN MEDICATIONS):

Student will have completed Medication Cards available for Clinical Instructor/RN preceptor to review.

Generic name: / Brand name:
Classification:
Action:
Why is YOUR patient/client receiving this medication
Dosage/Route: / Dosage/Route prescribed client:______
Is dose within recommended dosage ranges? YES NO / Rate of administration with IV meds:
IV diluents compatiblewith IV medication:
Major side effects: / Side effects my client is experiencing:
What data is used as an indicator that the medication is effective:
Medication administration concerns:
Relevant patient/client teaching points:

Source:

1

CON CPT: Revised 1/05; 12/08; 10/09; 3/13

Diagnostic Results: Include abnormal lab results only.

Test

/

Normal Value

/

Date

/

Date

/

Date

/

#1-Rationale for abnormal value

#2- Nursing Interventions
WBC (Total) / Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
RBC

Hgb

Hct

Plt

PT

INR

Fibrinogen

PTT

Anti -Xa

Na

K

Cl

CO2

Magnesium

Phosphorus

Anion Gap

BUN

Creatinine

BUN/Creat. Ratio

Glomerular Filtration Rate

Glucose

Ca

Bilirubin (Total)
Conjugated Bili.
AST (SGOT)
ALT (SGPT)
Total Protein
Albumin
Albumin/Globulin
Alkaline Phos.
Diagnostic Results: Include abnormal lab results only.

Test

/

Normal Value

/

Date

/

Date

/

Date

/

#1-Rationale for abnormal value

#2- Nursing Interventions

Ammonia

/ Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:
Abnormal Lab Result______
Rationale:
Nursing Interventions:

Lipase

Amylase

BNP

Lactic Acid-Venous
CK-MB or
Troponin
(Serial 1-3)
Drug Levels
ABG’s
Diagnostic
Procedure Results
Microbiology
(Cultures)
Imaging Results
Other Misc.
Diagnostics:

1

CON CPT: Revised 1/05; 12/08; 10/09; 3/13

Time Management Table
Nursing Interventions / Pending Diagnostics / Time (Date)
0700 / 0800 / 0900 / 1000 / 1100 / 1200 / 1300 / 1400 / 1500 / 1600 / 1700 / 1800
Nursing Interventions without a specific time (i.e.MD call parameters, activity instructions, directions for dressing changes)*

*If very lengthy you can summarize but you are responsible for being aware of the information.

1

CON CPT: Revised 1/05; 12/08; 10/09; 3/13

Nursing Care Plan  CJT

Student Name: Date:

Patient Initials: Patient Medical Diagnosis:

Nursing Diagnosis (Use PES format): (Note: use information from medical chart to complete evidence portion)

Assessment Data

Include all the following that apply to and support the N.D.Subjective: What patient and family say.
Objective: Vital Signs, Diagnostics, Physical Assessment, History /

Goals/Outcome Criteria

(Use SMART format: pt/family centered/specific; action-oriented; measurable; time-specific; and realistic. Provide 2-3 goals/outcomes) /

Nursing Interventions

(List all nursing and multidisciplinary interventions that will assist this patient in meeting goals; include teaching and discharge planning) /

Rationale

(Provide reason why for each intervention is indicated/therapeutic; provide references as appropriate) / Outcome Evaluation and Revision of Plan
#1-Were goals met?
#2-How would you revise the plan of care according to the patient’s response to current plan of care?

NCP Continued

Assessment Data

Include all the following that apply to and support the N.D.Subjective: What patient and family say.
Objective: Vital Signs, Diagnostics, Physical Assessment,History /

Goals/Outcome Criteria

(Use SMART format: pt/family centered/specific; action-oriented; measurable; time-specific; and realistic. Provide 2-3 goals/outcomes) /

Nursing Interventions

(List all nursing and multidisciplinary interventions that will assist this patient in meeting goals; include teaching and discharge planning) /

Rationale

(Provide reason why intervention is indicated/therapeutic; provide references as appropriate) / Outcome Evaluation and Revision of Plan
#1-Were goals met?
#2-How would you revise the plan of care according to the patient’s response to current plan of care?

NCP Continued

Assessment Data

Include all the following that apply to and support the N.D.Subjective: What patient and family say.
Objective: Vital Signs, Diagnostics, Physical Assessment,History /

Goals/Outcome Criteria

(Use SMART format: pt/family centered/specific; action-oriented; measurable; time-specific; and realistic. Provide 2-3 goals/outcomes) /

Nursing Interventions

(List all nursing and multidisciplinary interventions that will assist this patient in meeting goals; include teaching and discharge planning) /

Rationale

(Provide reason why intervention is indicated/therapeutic; provide references as appropriate) / Outcome Evaluation and Revision of Plan
#1-Were goals met?
#2-How would you revise the plan of care according to the patient’s response to current plan of care?

1

CON CPT: Revised 1/05; 12/08; 10/09; 3/13