Student Name: Marissa Schmidt Faculty Name: Red Date: _03/28/23
Weekly Nursing Process Worksheet
Instructions: Each clinical day each student will
... [Show More] develop a 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 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
Know the admitting diagnosis and hold status X
Read the most recent physician and nursing notes. 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
IDENTIFICATION DATA:
Patient Initials: JD Patient Age: 33 Gender F M Allergies Isolation:
Other:
SITUATION
I am reporting about: Patient initial: Room #
The problem and situation I am reporting about is: Patient is presenting with intractable nausea and vominting related to adenocarcinoma of the appendix. CT showed moderate numbers of ascites, soft tissue nodularity along the right hepatic
margin, retroperionterial adenopathy subcm ormental nodules.
Problem: the patient is experiencing nausea and vomiting.
Situation: Hypothermic intrapreneurial chemotherapy.
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: hypothermic intrapreneurial chemotherapy Surgery:
N/A
BACKGROUND
• Briefly state why the patient is in the hospital give a synopsis of the treatment to date.
I am reporting about is: Patient is presenting with intractable nausea and vominting related to adenocarcinoma of the appendix. CT showed moderate numbers of ascites, soft tissue nodularity along the right hepatic margin, retroperionterial adenopathy subcm ormental nodules.
Dr Debra Wallace 12/14/2021 Med/Surg
• What is the admission plan? Hypothermic intranuerial chemotherapy
• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none) Most Recent Vitals:
Temperature: 98
RR: 100
Respirations: 20 BP: 119/80 SpO2: 94
Pain: unknown
• Relate the complaint given by the patient e.g., pain and anxiety level. Exeperiencing nausea and vomiting.
• Relate the physical assessment pertinent to the problem, especially any changes. Heart is slightly elelvated due to pain.
• Pay special attention to mental status, skin temperature and emotional state of the patient
Glascow Coma Scale is 15. A&0x4
PERTINENT HISTORY: (include pertinent history)
DM/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia
Metastatic adenocarcinoma Drug: Marijuana use weekly Former smoker quit 4/22
Psych: Unknown Living Situation: unknown
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) Pt is at risk for CVA and falls due to her past medical history.
If the situation is unclear at least try to indicate what body system might be involved. Nuero, GI and Inguinal system
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels) Condtion appears to be moderate in nature as per the medical history
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)
The adenocarcinoma could be life threatening due to the severity of the other symptoms.
ANALYSIS OF ASSESSMENT: use the template on the next page [Show Less]