Weekly Nursing Process Worksheet
Instructions: Each clinical day each student will 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.     YES    
Know the admitting diagnosis and hold status YES    
Read the most recent physician and nursing notes. YES    
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)

 YES    
IDENTIFICATION DATA:
 

Patient Initials: G.J. Patient Age: 74 Gender    F    M     Allergies      NKA, NKDA       Isolation: N/A

  Other: __________ 

SITUATION 
I am reporting about:  A 74 year old male patient Patient initial: G.J Room #201A
The problem and situation I am reporting about is:
Problem: Patient has pain due to a fall, subtle hazy and nodular opacities of the bilateral lungs are notes which present infection (pneumonia),

 
Situation:

 
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)?

74 year old male was admitted into the hospital on April 20th of a chief complaint of a fall. As per the patient he got up to go to the bathroom, and on his way back he fell. He says he tripped on his own feet. The family reported that the patient had been in bed for 3 days. The patient denied any chest pain, shortness of breath, fevers, chills, palpitations or abdominal pain. He denied any prodrome prior to fall. Patient had a cardiac cath about 10 years ago which was negative for significant CAD.

 

Admitting DX: Patient is admitted for Non-ST Elevation MI (NSTEMI) and type 2 MI (supply/demand) . Surgery: N/A
 
BACKGROUND
●        Briefly state why the patient is in the hospital give a synopsis of the treatment to date.
●        What is the admission plan?
●        Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none)

Blood pressure (128/81 mmHg), Heart rate (97 bpm), Temperature (97.7 F or 36.5 C), Respiration rate (15 breaths/min), O2 saturation (98%)
●        Relate the complaint given by the patient e.g., pain and anxiety level.

Patient verbalizes pain of 0/10 on pain scale and is feeling “fine”
●        Relate the physical assessment pertinent to the problem, especially any changes.

 
●       Pay special attention to mental status, skin temperature and emotional state of the patient

Patient has good eye contact, responsive, well-nourished, normal speech, appears comfortable, warm to the touch
PERTINENT HISTORY: (include pertinent history)
 

DM/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVD/COPD/Smoker/ETOH/Drug Abuse/Dementia/ DVT/ SAH

Hypertension, Hyperlipidemia, Heart Failure, Myocardial Infarction, Dementia, COPD,

 

 Psych: HAPPY          Living Situation: Patient lives in nursing care at CVS SNF
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)

 
If the situation is unclear at least try to indicate what body system might be involved.
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels)

 
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: