Student Name: Faculty Name: _Tustin Date:
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: M.M Patient Age: 87 Gender F M Allergies Sulfa, codeine Isolation:
_NONE Other:
SITUATION
I am reporting about: increased pain Patient initial: M.M Room # 224
The problem and situation I am reporting about is:
Problem: The patient is having a pain level of 7/10 in her hip
Situation: The patient is experiencing a suspected pelvic fracture from a possible fall prior to the hospital and is going to the x-ray, can we increase her pain medication
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: Stroke Surgery:
BACKGROUND
• Briefly state why the patient is in the hospital give a synopsis of the treatment to date.
On 11/8/22, the 87-year-old patient began to feel RUE weakness and numbness; she was unable to move her right arm on and was brought into the hospital. The CT scan showed an acute intracranial hemorrhage in the bilateral frontal lobes and left the periodic region. The CTA showed no LVO, acute dissection, or aneurysm, and she had a hypertensive crisis of 208/92.
Dr Debra Wallace 12/14/2021 Med/Surg
• What is the admission plan?
Have the patient participate in physical therapy to increase her mobility and function on her right side. To tune her fine motor skills, balance, and return to prior level of function. PT/OT, pain management, medication management, monitor labs, monitor vitals
• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none) None
• Relate the complaint given by the patient e.g., pain and anxiety level.
The patient is feeling 8/10 on the anxiety level and is showing an increase to 7/10 on the pain scale on her hip
• Relate the physical assessment pertinent to the problem, especially any changes. Acute onset of RUE weakness and numbness
• 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: Normal, occasionally slow to respond Living Situation:
Alone
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 might have a fractured hip from a previous fall before she was admitted to the hospital, and needs an x-ray to confirm ASAP
If the situation is unclear at least try to indicate what body system might be involved. The body system involved might be neuro and possibly musculoskeletal
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels) The patient is having moderate pain on her hip due to possible fracture
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:
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