Nursing Process Worksheet (NPW) [1st and 2nd Semester]

Date of care: _______Student: _____________________________ Patient Initials: ___Room#: ______ Age/Sex: ____ Admit Date: ______ Code Status: _____________________ Primary language: _______________ Fall risk __Y__N Allergies: __________________________ Surgery Date: ______ Name of Surgery: __________________________________________________ Please obtain from H&P Admitting Dx: ___________________________________________________________________________________________________________ History of present illness: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Past Medical/Surgical Hx: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Course of events in hospital (obtain from progress notes): _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ MD Orders (Please obtain from physician orders in the chart):

Vital Sign freq: I & O: NGT:

IV Fluid (rate & solution): Foley: JP/Drains:

Peripheral IV: Central Line: Activity: Isolation:

Diet//NPO: O2: Hemodialysis Days:

Fluid Restriction: Accuchecks freq: Seizure Precautions:

Tube feedings (type, solution, rate): Therapy: PT OT ST RT

Wound Care:

Labs to be drawn/Specimens to be collected:

Special Tests/procedures s (x-ray, surgery, etc):

Misc:

NPW 1st and 2nd Semester]

NOTES FOR DAY OF CARE

Primary Nurse:

CNA:

Student Team Coordinator:

Patient Teaching

•

Discharge Plans

•

VITAL SIGNS/PULSE OX INTAKE & OUTPUT NEW ORDERS/MISC NOTES

Prior shifts VS/Pulse Ox

________________________

Shift VS/Pulse Ox

_________________________

_________________________

_________________________

_________________________

Prior 24 hr I_______ O______

Intake

Breakfast________

Lunch_______

Dinner_________

Output

________ _________ _______

BM ________

AM Weight __________

BLOOD GLUCOSE/INSULIN PATIENT PROBLEMS

Before breakfast__________ Insulin_________________ Before lunch_____________

Insulin________________ Before dinner____________ Insulin________________

NPW [1st and 2nd Semester] Medication Chart

Drug (trade/generic) Class (functional/chemical)

Action Recommended Dosage Range

Prescribed Dose

Route Frequency Time Indication for this patient

Nursing Implications

NPW [1st and 2nd Semester]

Medication Chart Drug (trade/generic)

Class (functional/chemical) Action Recommended

Dosage Range Prescribed

Dose Route Frequency Time Indication for

this patient Nursing Implications

NPW [1st and 2nd Semester] Laboratory & Diagnostic Results

LAB Normal Range

Patient Result

Rationale for Abnormal Result

Nursing Implications

LAB Normal Range

Patient Result

Rationale for Abnormal Result

Nursing Implications

Electrolytes/

Chem Panel

CBC

NA+ RBC

K+

WBC

CL-

Hgb

Ca+

Hct

Mg+

Neutrophils

Phosphorus

Eosinophils

Creatinine

Basophils

BUN

Lymphocytes

Albumin

Monocytes

Glucose

CO2

Coagulation

ABG’s

PT

PH

PTT

PCO2

Platelets

PO2

INR

HCO3

Cardiac

SaO2

Troponin

Liver

BNP

Albumin

CK-MB

Ammonia

Other cardiac

labs on reverse

Bilirubin

Total Protein

SGOT

ALT

AST

Drug Levels

Pancreas

Dilantin

Lipase

Digoxin

Amylase Other:

Diabetes

Lactate

HgbA1C

Cardiac

Continued

Total

Cholesterol

HDL

LDL

Triglycerides

C-Reactive

Protein

NPW [1st and 2nd Semester] DIAGNOSTIC TESTS

Diagnostic Test

Patient’s Result How does result relate to diagnosis

Rationale for abnormal result

NPW [1st and 2nd Semester] Textbook Picture Example

Disease Process: Type 2 Diabetes

Chronic Disorder of carbohydrate metabolism with subsequent alteration of protein and fat metabolism characterized by hyperglycemia resulting from lack of insulin, lack of insulin effect, or both.

• Pathophysiology: Diabetes affects the way the body uses food to make the energy for life. Genetic factors are significant, and onset is accelerated by obesity and a sedentary lifestyle. The pancreas produces some insulin, but it’s either too little or ineffective. The following factors contribute to its development:

✓ Impaired insulin secretion ✓ Inappropriate hepatic glucose production ✓ Peripheral insulin receptor insensitivity

• Etiology: Beta cell exhaustion due to lifestyle habits or hereditary factors.

• Risk Factors: Obesity, family history, ethnicity (Black, Hispanic, or Native American)

• Signs & Symptoms: polyuria, polydipsia, polyphagia, weight loss, headache, fatigue, lethargy, reduced energy level, muscle cramps, irritability, emotional lability, vision changes (blurring), numbness & tingling, abdominal discomfort and pain, nausea, diarrhea, or constipation, slowly healing skin infections or wounds, skin itching, vaginal pruritus and vulvovaginitis.

• diagnostic test: FBS, RBS, Glucose tolerance test, Hemoglobin A1C

• Medical management (pharmaceutical and non-pharmaceutical) ✓ Oral anti-diabetic drugs ✓ Insulin therapy ✓ Monitoring blood glucose levels ✓ Individualized meal plan

✓ Weight reduction ✓ Regular, daily exercise ✓ Patient and family education

• Nursing Diagnosis and desired outcomes ❖ Risk for Unstable Blood Glucose level r/t inadequate blood glucose monitoring, dietary intake, and/or medication management.

✓ Patient will have a blood glucose <180 mg/dL at all times ✓ Fasting blood glucose < 140 mg/dl when hospitalized ✓ Hemoglobin A1C < 7 ✓ Adequate perfusion (warmth, sensation, brisk capillary <

2 sec ✓ Peripheral pulses > 2+ on a 0-4+ scale ✓ BP within optimal range ✓ Urinary output 30 mL/hr ✓ Baseline vision ✓ Good appetite ✓ Absence of nausea/vomiting ✓ Demonstrates adherence to therapeutic regime

❖ Risk for Infection r/t chronic disease process (hyperglycemia, neurogenic bladder, poor circulation ✓ Asymptomatic for infection (afebrile, negative cultures, and WBC 11,000/mm or less

❖ Risk for Impaired Skin Integrity r/t altered circulation and sensation occurring with peripheral neuropathy and vascular pathology. ✓ Lower extremity skin intact ✓ Within 24-hr period before discharge, patient verbalizes and demonstrates knowledge of foot care.

❖ Deficient Knowledge r/t unfamiliarity with proper insulin administration, dietary precautions, and exercise for promoting normal blood sugar. ✓ Within 24-hour period before hospital discharge, patient verbalizes and demonstrates knowledge of proper insulin administration, symptoms and

treatment of hypoglycemia, the prescribed dietary regimen, and the role of exercise in promoting normal blood sugar ❖ Altered nutrition: Less than body requirements r/t decreased oral intake, nausea, vomiting, and insulin deficiency.

✓ Patient will have optimal nutritional status (food and fluid intake, nutrient intake, energy, endurance) ❖ Patient Teaching

✓ Diet ✓ Medication (oral or Insulin) ✓ Blood testing ✓ Skin care ✓ Circulation

STUDENT: _________________________________ Textbook Picture

Include boxes for: ➢ diagnostic test ➢ Medical management (pharmaceutical and non pharmaceutical) ➢ Nursing management (interventions) ➢ Patient Teaching

Etiology Pathophysiology

Disease Process

Risk Factors Signs & Symptoms

What students are expected TO DO…during clinical

Note: This list may be modified by your clinical instructor and unit assigned

Time Frame Done Tasks and Responsibilities

0600-0700 o Check to see that patient is not discharged and check Cerner for new orders/plans

0600-0700 o Review and record NPO status, diet order, medications, and current laboratory/imaging/diagnostic test results

0700 o Receive patient report

0730 o Check patient status, surroundings, do quick clean-up of patient environment, and sanitize bedside table

0730 o Prioritize Tasks and cover sliding scale insulin if applicable

0745 o Take vital signs, perform am care, and pass breakfast trays

0800 o Check medication schedule and look up new medications

0800 o Make sure patient has cup, water, straws, applicable laboratory results available, blood pressure within 15 minutes of antihypertensive medication, and ascertain if patient can swallow or if medication requires crushing

0800-1000 o Perform nursing assessment within first two hours of shift & document in Nursing Process Worksheet/Student Nursing Note

0730-1700 o Give meds as scheduled throughout shift with instructor supervision

1030-1130 o Give report to instructor

0900-1700 o Document intake and output including meal intake throughout the shift

0700-1700 o Perform tasks and skills (bed bath, hygiene, ROM, NG feedings, positioning, dressing changes, Foley cath, etc.) with instructor supervision as indicated

0700-1700 o Make hourly rounds on your client per facility protocol

0700-1700 o Provide ROM, perineal care, and oral care every two hours and PRN for bedbound/total care patients

0700-1700 o Check for new MD orders and progress notes ideally every two hours throughout the shift

1200 o Perform 1200 vital signs and Accucheck if applicable, pass lunch trays, and document intake

0700-1700 o Document narrative charting every two hours on Nursing Process Worksheet nursing notes Open chart at 0800, closing note at 1630 includes “report complete to __________RN” and update/resolution of problem list

1600 o Perform 1600 vital signs, and make sure that all vital signs are documented in Cerner patient management system correctly

0700-1700 o Maintain open communication with instructor throughout the shift regarding patient condition, needs, and if applicable accompany patient to diagnostic tests and procedures

0700-1700 o Complete documentation throughout the shift as charting cannot be taken home All entries must include your first initial and last name followed by “LATTC SN”

0700-1700 o Give report to staff nurse team coordinator (if applicable) before leaving unit for break, lunch, and post conference

1630-1700 o Check patient environment and condition before leaving unit and give report to staff nurse

0730-1700 O Provide patient centered care throughout the shift informing the instructor of interpersonal challenges if any

ASSESSMENT CRITERIA NEUROLOGICAL

• LOC (level of consciousness) o A/O x 4 (alert & oriented to name, time, place, &

situation

• Verbal response o Clear o Incoherent, rambling, slurred, stuttering o Dysphasia, aphasia

• Motor response o Grips (note strength weak or firm) o Obeys commands, localizes pain, withdrawal,

flexion, extension, none.

• Pain o Pain-sharp, burning, intense, sudden, agonizing,

throbbing, stabbing o Pain level 1-10: onset, duration, location, intensity,

quality, pattern, relief measures

• Assess pupils o Note shape o Pupils equal, round, react to light, and

accommodate (PERRLA) ▪ 1 mm after surgery ▪ 2-3 mm normal ▪ 6-9 mm “blown”; if permanent, possible

herniation INTEGUMENTARY

• General Appearance o Pale, flushed, cyanotic, discolored, freckled o Moist, diaphoretic o Hot, warm, cold o Dry, scaly, oily o Rash, abrasion, laceration, incision, broken, sores,

lesions, scars, calloused, contusions o Tanned, glossy, tattoos o Swollen, coarse or fine texture

• Turgor o Immediate recoil, tenting

• Integrity o Intact, impaired o Wound vac/dressing

• Mucus membranes o Color, condition

CARDIOVASCULAR

• Apical, B/P, radial, peripheral pulses (present <, = bilaterally, >)

o Rate/rhythm ▪ Regular, irregular, strong, rapid, weak,

absent, thready o Intensity o Doppler

• Skin pale, flushed, cyanotic, discolored, moist, cold, clammy

• Edema-pitting, non-pitting

• Capillary refill < 3 seconds

• Sequential compression device (SCD)

• IV/IVF, Saline lock, PICC/Central line RESPIRATORY

• Breathing o Dyspnea, apnea, deep/shallow

• SOB o With which activities

• Chest

• o Excursion symmetrical/asymmetrical

• Lung sounds o Clear, rales, crackles, rhonchi, wheezes

• Sputum o Clear, thin, thick, tenacious o Note color

• Measure O2 saturation o Pulse oximeter

• Oxygen L/min GASTROINTESTINAL

• Abdomen o Soft, firm, rigid, tender, sensitive to touch o Enlarged, distended, flat, round o Note rebound tenderness

• Bowel sounds (listen to all 4 quads-2-5 minutes) o Normal, faint, hypo, absent, hyper)

• BM size (small, medium, large)

• Diarrhea (amt/color/freq)

• Ostomy

• Nasogastric/feeding tube

• Nausea/vomiting) amount, color, frequency o ml or small/ large amount o Blood tingled, fecal o projectile

• Appetite (tolerance to prescribed diet) o Percentage

GENITOURINARY (normal output 30 ml/hr)

• Urination: independent, catheter, intermittent o Amount o Color-yellow, amber, bloody, brown, dark red o Appearance-clear, cloudy, sediment o Odor-offensive, foul, musty, aromatic, ammonia-

like, odorless o ostomy

• Intake & output-all fluids should be balanced with output

• Bladder distension o Check, feel, palpate

MUSCULOSKELETAL

• ROM

• Swelling/tenderness

• Gait/balance

• Deformities PSYCHOSOCIAL

• Mental & spiritual

• Moods

• Affect

• Judgment

• Abilities,

• Lifestyle

• Patterns,

• Age

DATE/TIME DOCUMENTATION

STUDENT NAME: _____________________________________

CLIENT INITIALS: _________________ DATE: ____________________

____________________________

D

STUDENT NAME: _____________________________________

CLIENT INITIALS: _________________ DATE: ____________________

____________________________

D

DATE/TIME DOCUMENTATION

PHYSIOLOGICAL: NEUROLOGICAL LOC: __awake __alert__ lethargic __ confused __ forgetful __easy to arouse __difficult to arouse__Unresponsive __combative __agitated Verbal response: __clear __slow __ incoherent __rambling __slurred __stuttering __dysphasia ___aphasia Pupils: ____________ __ Follows command Orientation: __person __place __time __ situation

* Nursing DX: *PRIORITY: _________

PHYSIOLOGICAL: GASTROINTESTIONAL Oral Cavity: __moist __dry Appetite: __good __fair __poor Abdomen: __soft __firm __rigid __ tender __flat __round __distended __obese __painful __nausea __vomiting (amt, color, freq) ______________________ Bowel Sounds: __present __hypoactive __hyperactive __absent Bowel Pattern: __continent __incontinent __constipated diarrhea (amt/color/freq) ________ __cramping Last BM _____ size/color_______ Ileostomy: ____________ Colostomy____________ bag size____ Tubes/Drains: __________________________ __clamped __gravity Suction __LIS __LCS __HCS Tube feeding___________________________________ *Nursing DX: * PRIORITY: _________

PHYSIOLOGICAL: PAIN Pain Score ____/10 Comfort Score ____/10 Location: ___________________ Quality: __aching __burning __constant __dull __radiating __sharp __throbbing __pressing __stabbing __shooting __ cramping __intense __sudden __agonizing Duration: __ continuous __ intermittent __ positional Pain Medicine effective __yes __ no Pain device: PCA setting_____________ TENS____________ *Nursing DX: * PRIORITY: _____

PHYSIOLOGICAL: RESPIRATORY Breathing pattern: __regular __ dyspnea __ apnea __ deep __ shallow __ SOB with activities Chest excursion: symmetrical__ asymmetrical__ Breath sounds: __bilateral clear decreased__ R __L Absent __R __L crackles __R __L rales __R __L rhonchi __R __L wheezes __R__L Cough: __none __wet __dry __productive __nonproductive Sputum: __none __present __thin __thick __tenacious __frothy Sputum Color: __clear __yellow __green __blood tingled __pink Oxygen: ___/liters Tracheostomy __yes __no type/size ___ Respiratory equipment: __________________________ *Nursing DX: * PRIORITY: ____

PHYSIOLOGICAL: GENITO-URINARY Voiding: __Continent __incontinent __urgency __frequency __painful/difficult Color: __yellow __amber __bloody __dark red __brown Appearance: __clear __cloudy __sediment odor __Y__N __Has not voided __bladder distension Foley __condom catheter __suprapubic catheter __3-way irrigation __urinary diversion(ostomy) __Hemodialysis __CAPD *Nursing DX: * PRIORITY: _________

Medical Diagnosis_____________________ Physiological Nsg Dx:_______________________Psychosocial Nsg Dx (2nd semester): _____________________

Assessment Sheet (1st and 2nd Semester)

PHYSIOLOGICAL: CARDIOVASCULAR Pulse Rhythm: ___regular ___irregular Pulse Intensity: (N=normal S=strong R=rapid W= weak T=thready A=absent D=doppler) ___Apical Radial ___R ___L Femoral ___R ___L ___ Post tibia ___L Dors Pedis ___R ___L Edema: __none __mild __moderate __severe __pitting __nonpitting location: ____________ Devices: __ICD __Pacemaker __AV fistula __ thrills __ bruit Other______________ Sequential compression device (SCD) __ on __off TED hose __on __off__ IV site: __Peripheral IV __Saline lock __PICC line __Central Line forearm __R__L upper arm __R__ L hand __R L__ antecubital __R__L neck R__L__ __chest IV Site assessment: __no signs of infiltration __swelling __pain __drainage IV solution___________________________________________________

*Nursing DX: * PRIORITY: _________

PHYSIOLOGICAL: MUSCULO-SKELETAL Gait: __unable to assess __unsteady __steady __uses cane/walker/crutches Activity: __ab lib __bedrest __BRP __chair __ ambulate without assist ambulate w/assist of ____ transfer w/assist of ____ Devices: __Traction – Type__________ Splint/Brace – Type__________________ __Cervical collar __sling Cast: __short __Long Deformities________________ PERIPHERAL NEURO-MUSCULAR Sensation: not able to assess Normal Numbness Tingling no sensation RUE __ __ __ __ __ LUE __ __ __ __ __ RLE __ __ __ __ __ LLE __ __ __ __ __ Movement: Not able to assess strong weak absent RUE __ __ __ __ LUE __ __ __ __ RLE __ __ __ __ LLE __ __ __ __ *Nursing DX: * PRIORITY: _________

Medical Diagnosis_____________________ Physiological Nsg Dx:_______________________Psychosocial Nsg Dx (2nd semester): _____________________

Assessment Sheet (1st and 2nd Semester)

PHYSIOLOGICAL: INTEGUMENTARY Skin Color/Condition: __warm __hot __cool __dry __scaly __ oily __moist ___diaphoretic __pale __flushed __cyanotic __jaundiced __ecchymosis __rash Skin Turgor: __immediate recoil __tenting Skin Integrity: __intact __abrasions __lacerations other: ______________________________ Surgical Incision: location________________ __Sutures __staples __steri strips __redness __tenderness __swelling Describe: __________________________________________________________ Pressure ulcers: __none present __Stage 1 __Stage 2 __Stage 3 __Stage 4 Describe: __________________________________________________________ __________________________________________________________________ Dressings (location): ________________________________________________ __Dry/intact __stained __saturated __wound vac Specialty bed: ______________________

Sensory Perception Completely limited =1 Very limited =2 Slightly limited =3

No impairment =4

Mobility Completely Immobile =1 Very limited =2 Slightly limited =3

No limitations =4

Moisture Constantly moist =1

Very moist =2 Occasionally moist =3

Rarely moist =4

Nutrition Very poor =1

Probably inadequate =2 Adequate =3

Excellent =4

Activity Bedfast =1 Chair only =2

Walks occasionally =3 Walks frequently =4

Friction/ Shear

Problem =1 Potential problem =2

No apparent problem =3

Score < 18 = Implement Interventions BRADEN TOTAL SCORE:

PRESSURE ULCER RISK ASSESSMENT BRADEN SCALE – circle score for each & total

* Nursing DX: * PRIORITY: ___

SAFETY & SECURITY NEED Hand grasps: __firm __weak __paralysis __seizure activity Memory intact: long term__ Y__N short term __Y__N Orientation: __Person __Place __Time __Situation Senses: __wears glasses __wears hearing aid Mobility: __gets up without assistance __wandering __compliance or combative with ADLs Safety equipment used___________________ FALL RISK ASSESSMENT – circle score for each and total

History of falling No = 0 Yes = 25 IV therapy/saline lock No = 0 Yes =20

Secondary DX > 1 No = 0 Yes 15 Gait/BR/WC = 0

Ambulatory aid Weak = 10

None/BR/Assist = 0 Impaired = 20

Crutches/cane walker

= 15 Limitations: Knows own

= 0

Furniture = 30 Forgets limitations = 15

Score > 45 = Implement interventions Fall Total Score:

*Nursing DX: * PRIORITY: _________

PSYCHO-SOCIAL: SELF-ESTEEM SELF CARE

PSYCHO-SOCIAL: SELF ACTUALIZATION Medical Diagnosis_____________________ Physiological Nsg Dx:_______________________Psychosocial Nsg Dx (2nd semester): _____________________

Assessment Sheet (1st and 2nd Semester)

Los Angeles Trade-Tech College NURSING PROCESS

Mobility/ADLs: Independent Assist Unable Turning __ __ __ Sitting __ __ __ Ambulating __ __ __ Toileting __ __ __ Bathing __ __ __ Grooming __ __ __ Eating __ __ __ __Dress/grooming/Hygiene neglect Communication ability: __intact __impaired __use of communication aids Emotional status: ___Eye Contact ___calm __labile __irritable __anxious __angry __happy __fearful __withdrawn __combative Coping: __feels sorry for self ___able to make needs known Involvement with plan of care: __active __passive __unable to participate ___Alcohol/drug use __Living Will Statement about Health Situation:

*Nursing DX: * PRIORITY: _________

Religion _______________ Ethnic/Cultural Background____________________ EDUCATION/TEACHING: ____Patient ___Caregiver __other Educational level______ Dominant language________ _____Learning Disabilities Identified Needs __ Self-care __signs & symptoms to report __medication __treatments/procedures __activity __diet/nutrition __use of medical equipment __pain management __food & drug interactions __fall risk __safety __ isolation __wound care __other Statements about Past life/Life Changes:

*Nursing DX: * PRIORITY: _________

Medical Diagnosis_____________________ Physiological Nsg Dx:_______________________Psychosocial Nsg Dx (2nd semester): _____________________

Assessment Sheet (1st and 2nd Semester)

Assessment Nursing Diagnosis Goals

Nursing Interventions (Dependent, Independent

& Collaborative

Rationale of Nursing Intervention

Evaluation

Collection of data on a specific problem from a variety of sources including: physical assessment; chart; patient and family interviews.

Subjective Data: Information the patient tells the nurse. Quote the patient. Include patient’s pain rating and threshold.

Objective Data: Information collected by the nurse’s sense (see, hear, smell, and palpate). Include vital signs, applicable lab and test

results.

1). State nursing diagnosis in 2 or 3-part statement. Must be NANDA, and cite

2). Define NANDA

Diagnosis 3). State rationale for selecting this dx.

State the patient-centered goal. Identify outcome criteria to measure achievement of the goal. Must include: WHO (e.g., patient will) WHAT HOW (condition)

HOW WELL (criteria) WHEN (date and time goal is to be evaluated) S - specific M - measurable A - attainable R - realistic T - time

Specific actions the nurse takes to assist the patient to achieve the goals. Must be specific interventions for this patient. Organize the paper to identify which intervention addresses which short term goal. Include:

Further or continued assessments. Therapeutic measures and preventive measures (do). Teaching Plan. What? Why? How? Who are the participants?

Each intervention must be supported by a rationale. In the first semester each rationale must have a written

source (book, professional

journal, or professional web site) and page number for print

materials. A reference list of the written sources must be included with all ANPs. In the second, third, and fourth semester interventions must be supported by scientific rationale.

Evaluate the extent to which the stated outcome criteria have been achieved. What needs to be modified? -diagnosis? -goal? -intervention?

Los Angeles Trade-Tech College

NURSING CARE PLAN

Patient Initials: ___________________ Date(s) of Care: ________________ Student Name: ________________________________ Medical Diagnosis: _______________________________________________ Date Submitted: _________________________________

Assessment Nursing Diagnosis Goals

Nursing Interventions (Dependent, Independent

& Collaborative

Rationale of Nursing Intervention

Evaluation

Subjective Data: Objective Data: