materials

1. Nursing Process Worksheet
nursing report and need a reference to help me learn.
I have completed half the worksheet, please just try filling it out more accurately based off
of the patient info i have provided. Please make sure it is fully completed, especially the
medication list
Requirements: worksheet
Student Name: ______________________________ Faculty Name: ________________ Date: _____________
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. Know the admitting diagnosis and hold status Read the most recent
physician and nursing notes. 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) IDENTIFICATION DATA: Patient Initials: ________Patient Age: _______
Gender F M Allergies _________ Isolation: ___________ Other: __________ SITUATION I
am reporting about: Patient initial: Room # The problem and situation I am reporting about
is: Problem: 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)? Admitting DX: _____________________________________________Surgery:
____________________________________ BACKGROUND •Briefly state why the patient is in the
hospital give a synopsis of the treatment to date.

2. •What is the admission plan?•Give the vital signs, pain level, oximetry, and how much
oxygen is being given. (If none state none)•Relate the complaint given by the patient e.g.,
pain and anxiety level.•Relate the physical assessment pertinent to the problem, especially
any changes.•Pay special attention to mental status, skin temperature and emotional state
of the patientPERTINENT HISTORY: (include pertinent history) DM/GI/GERD/GU/ HTN/
CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia Psych:
__________________________ Living Situation: __________________________ 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 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: Student Instructions: In the space below,
enter the subjective and objective data gathered during your client assessment. P HR RR T:
SaO2 Assess Pain: (cm)____________ / (kg): __________System ↓ List the most important
anticipated physical / assessment steps that you will complete for this patient. (Citations
required). Describe the WNL Findings OR→ OBJECTIVE (Abnormal - Bullet Points) Potential
Complications. Based on your research, to what complications would your patient be prone?
List medical diagnoses- focus on complications that you can assess for or prevent. Include
potential collaborative therapy’s (Speech or Physical Therapy) SUBJECTIVE (Abnormal -
Bullet Points) What is the cause of the patients problem describing i.e., Pt is having SOB
8/10 with exertion
Dr Debra Wallace 12/14/2021 Med/Surg psychosocial/discharge planning complications
(Citations required). What is the cause of the patients problem describing i.e., Respirations
labored with intercostal retractions? Lung sounds diminished Neuro OR→ Cardio OR→ Resp
OR→ GI OR→ GU OR→ Skin OR→ Mobility OR→ Safety OR→ Psych-Soc OR→ Pain OR→ Need
Analysis of Laboratory Data/Treatments: ____________________________ What would you
anticipate as a result of this specific test result?Diagnostic Data: Exam Date Results
Interventions
MEDICATION LIST Medications Generic / Trade Class/Rationale for the patient
Dose/Route/ Time (Frequency) Mechanism of action Common side effects Nursing
considerations specific to this patient
TIME OUT!!! Student instructions: To be sure your critical thinking statement written below
is accurate, you need to review the defining characteristics and related factors associated
with and see how your patient data match. Do you have an accurate match or are additional
data required, or does another cue from abnormal assessment findings need to be
investigated? ABNORMAL ASSESSMENT FINDINGS: Recognize Cues Obtain information
from various sources (e.g., the environment, the pt., the family, another nurse, EHR) in
different formats (e.g., visual observation, audio perception, lab results, text description,
etc.). TIME OUT!!! Do you have an accurate match or are additional data required, or does
another cue from abnormal assessment findings need to be investigated? Assessment:

3. What are the identified abnormal findings: •List S&S= (Signs and symptoms, i.e., Abnormal
Subjective and Objective Assessment Findings/lab results,
etc.)______________________________________________________________________________________Analysis
Cues Interprets cues from their existing knowledge base and nursing perspective, evaluate
cues in terms of relevancy, importance, and interrelationship among other cues, organize
cues in the mental representation of the scenario (e.g., organize cues in clusters), and then
develops a group of probable client needs/concerns and problems. Prioritize Hypotheses
Evaluates the hypotheses generated previously in various dimensions (e.g., urgency,
likelihood, risk/difficulty/time/cost of providing care to that hypothesis, etc.), and organize
them into an ordered list where the priority hypotheses (i.e., client
needs/concerns/problems) are on the top. Analysis/Hypothesis: What is the cause of the
patients problem that must be prioritized at this time? •Evaluate the Hypothesis = (Signs
and symptoms, i.e., Abnormal Subjective and Objective AssessmentFindings/lab results,
etc.)_________________________________________________________________________________________Planning
(Patient goals focus on resolving the problem), Must be SMART goals Generate Solutions
Develops a list of actions to address the priority hypothesis. The student nurse then selects
the appropriate action from the list and carries out the action. TIME OUT!! The desired
outcome must meet criteria to be accurate. The outcome must be specific, realistic,
measurable, and include a time frame for completion. Does the action verb describe the
patient’s behavior to be evaluated? Can the outcome be used in the evaluation step of the
nursing process to measure the patient’s response to the nursing interventions listed
below? •Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease &
maintain)__________________________________________________________________________•by the: (end of
shift, end of day, discharge day) or within: (two hours; 12 hours,
etc.)____________________________________________________________________________________Implementati
on (Specific nursing interventions that were performed during your shift): Take Action
Sorts the hypotheses (probable client needs, concerns, problems) in order (based on their
evaluation in various dimensions) and carries out the action(s) to address the
hypothesis/hypotheses with highest priority. Must contain the following: Assess {observe,
auscultate, palpate, percuss}; Monitor; Prepare, administer; Collaborate w/ specific multi-
disciplinary team; & teach, i.e., VERBS
1._____________________________________________________________________________________2.________________
____________________________________________________________________3.___________________________________
__________________________________________________4._____________________________________________________
_______________________________Evaluation (What was the outcome: Did you meet your desired
goal?) TIME OUT!! Re-Assess the Patient: Do yourinterventions address further monitoring
of the patient’s response to your interventions and to the achievement of thedesired
outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the
action’s verb on thenurseGoal; Met or Not met or partially met and how to revise.)Goal: □
Met Goal: □ Not Met Goal: □ Partially Met Goal: □ Unable to Assess
How to Revise: __________________________________________________________________________Nursing
Application Assessment Include activities throughout the day performed in relation to the
following NCLEX content categories. See content category examples below as cited by

4. NCSBN Management of Care: (Nursing treatments provided to patient to help disease or
medical problem/s)
___________________________________________________________________________________________________
Safety and Infection Control (Measures done to keep patient and you are safe, to prevent
infection and worse condition)
___________________________________________________________________________________________________ Basic
Care and Comfort (Nursing measures given to patient to keep clean and comfortable)
___________________________________________________________________________________________________
Definitions of Above Management of Care: providing and directing nursing care that
enhances the care delivery setting to protect clients and health care personnel. Related
content includes but is not limited to: Advance Directives. Advocacy, Assignment,
Delegation and Supervision, Case Management, Client Rights, Collaboration with
Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security,
Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information
Technology, Legal Rights and Responsibilities, Performance Improvement (Quality
Improvement), Referrals Safety and Infection Control: protecting clients and health care
personnel from health and environmental hazards. Related content includes but is not
limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic
Principles, Managing Hazardous and Infectious Materials, Home Safety Reporting of
Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan,
Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of
Restraints/Safety Devices Basic Care and Comfort: providing comfort and assistance in the
performance of activities of daily living. Related content includes but is not limited to:
Assistive devices, Elimination, Mobility/Immobility, Non-Pharmacological Comfort
Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest STUDENT JOURNAL
Personal goals for the day: Experience (specialty areas) and activities of the day: Thoughts
about your experience today: (How did you meet your goal?) Your feelings about today:
(How can you utilize your experience in the future?)
N101L Nursing Process Worksheet - Pathophysiology Student
Name:____________________________ Faculty Name:___________________________ Date:____________
Directions: Complete, detailed pathophysiology of admitting diagnosis. Must include signs
and symptoms, risk factors, and complications. Must relate pathophysiology section back to
the patient. Supported with evidence-based citation(s). Admitting Diagnosis
Pathophysiology of Admitting Diagnosis Signs and Symptoms Risk Factors
Complications Relate Pathophysiology to the Patient