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nursing process worksheet

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nursing process worksheet

I'm working on a nursing report and need an explanation to help me understand better.

Please read the scenario and answer the questions. Upload the scenario with your answers and place it under week 1 nursing process worksheet. We will go over the scenario during pre conference next week. Fill out the worksheet using the report

Course: NURS 121L-A NURSING PROCESS WORKSHEET Date: ____________________________________________________________________________________ Student Name: Faculty Name: Instructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. These are quick writes and should be done throughout the shift and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows: Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Obj:_______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Subj:_______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Nursing Diagnosis (2) Must be prioritized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Etiology (Cause) : as evidenced by (Signs and symptoms) Abnormal Assessment Findings. (1)________________________________________________________________________________________ __________________________________________________________________________________________ (2)________________________________________________________________________________________ __________________________________________________________________________________________ Planning (Patient goals) Must be SMART goals Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ specific multi-disciplinary team; & Teach ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Page 1 of 2 Course: NURS 121L-A NURSING PROCESS WORKSHEET Evaluation (What was the outcome: Goal; Met or Not met or Partially met and How to revise.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ 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 ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Safety and Infection Control ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Basic Care and Comfort ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 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,

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