Student Name: Faculty Name: Date:
11-18-2022
Weekly Nursing Process Worksheet
Instructions: Each clinical day each student will develop a nursing
... [Show More] 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. X X X
Know the admitting diagnosis and hold status X X X
Read the most recent physician and nursing notes. X X X
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) X X X
IDENTIFICATION DATA:
Patient Initials: K.E Patient Age: _75 Gender F M Allergies Penecillin Isolation:
None Other:
SITUATION
I am reporting about: Patient initial: K.E Room #131
The problem and situation I am reporting about is:
Problem: Patient is post motor vehicle accident
Situation: patient
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)?
Admitting DX: Distal radius/ulnar fracture - S/P ORIF R mediaphyseal distal radius fracture and R ulnar shaft fracture, R 10-12 rab fractre, T11 VB fractures, L2-3 TP fracuutre Surgery: S/P ORID R mediaohyseal distal radius fractureand R ulnar fracture.
BACKGROUND
• Briefly state why the patient is in the hospital give a synopsis of the treatment to date.
On 10/29/22, the 75 year old patient was struck by a car and thrown 6 feet, upon arrival to the ER he was complaining of right wrist pain, and has multiple fractures to the spine
Dr Debra Wallace 12/14/2021 Med/Surg
• What is the admission plan?
PT/OT, pain managment, medicatio mangment, monitor labs, monitor vitals
• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none) Temp: 98, BP: 146/74, Pulse: 77, Resp: 18
• Relate the complaint given by the patient e.g., pain and anxiety level.
The patient reports a 5/10 on the 1-10 pain scale and has an anxiety level of 7 on a 1-10 scale.
• Relate the physical assessment pertinent to the problem, especially any changes.
The patient reports no sign of alterled mental state post accident however has a derease in cognition
• Pay special attention to mental status, skin temperature and emotional state of the patient
PERTINENT HISTORY: (include pertinent history)
DM/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia
Psych: _Altered Living Situation: Lives with wife and daughter and grandkids
ASSESSMENT:
Give your 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)
The patient is presenting with A/O x3 with an increased level of pain and anxiety, the patient might be suffering from tramatic brain injury based on the severity of his accident
If the situation is unclear at least try to indicate what body system might be involved. The system involved is musculockeltal and possibly neuro
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels) Patientis have severe right sided pain due to being hit by motor vehicle on his right side
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: [Show Less]