Student Name: Faculty Name: Tustin Date: 12/5/22
Weekly Nursing Process Worksheet
Instructions: Each clinical day each student will develop a
... [Show More] nursing 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 Judgment? 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: _PD Patient Age: _68 Gender F M Allergies Isolation: none
Other:
SITUATION
I am reporting about: Patient initial: PD Room #228
The problem and situation I am reporting about is:
Problem: The patient felt faint and light headed
Situation:The patient was in the shower with assistance from the CNA when he began to feel faint and almost fell in the shower. The patient says he had his head down and put his head up abruptly then began to see dots
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: Spinal cord injury Surgery: Laminectomy, spinal surgery
BACKGROUND
• Briefly state why the patient is in the hospital and give a synopsis of the treatment to date.
The pt was admitted on 11/10 to the OCG Er after falling in the bathroom and hitting his head in the front on the toilet and the back on the wall. He is post-surgery for a lumbar laminectomy a month before his accident on 11/10
Dr Debra Wallace 12/14/2021 Med/Surg
• What is the admission plan?
Assist the pt to get back to the level of function he was at before his injuries
• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none) Temp: 97.6, BP: 141/73 P: 55 Resp: 20
• Relate the complaint given by the patient e.g., pain and anxiety level. 9/10 pain in neck, R hand/elbow, back
• Relate the physical assessment pertinent to the problem, especially any changes.
-patient RUE continues to have 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: None Living Situation: _lives with wife and son
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 be have urine incontinence due to lack of mobility
If the situation is unclear at least try to indicate what body system might be involved. Urinary system
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels) The patient is having sudden urges to urinate, and he has a history of BPH
If appropriate, state the problem could be life threatening such as medication adverse effects.
(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:
Student Instructions: In the space below, enter the subjective and objective data gathered during your client [Show Less]