Client Initials

Culture/Ethnicity

Support system:

Unit 2 Room/Bed

Religion

Age Sex

Language

Weight Height

Current medical diagnosis

Marital status N/A

Occupation:

Siblings

Name of significant other/primary caregiver

Health insurance :

Current work status N/A

Highest grade completed

Genogram: See attachment

Diagnostic procedures:

Surgical procedures:

Pathophysiology/psychopathology (List reference)

Psychopathology:

DEVELOPMENTAL STAGE/THEORIST

Vital signs/Frequency

Allergies/Side effects

Diet with rationale Activity order

Limitations/prosthetic devices

Theorist:

BRIEF HEALTH HISTORY

PERTINENT LABORATORY

PERTINENT LABORATORY

PERTINENT LABORATORY

PERTINENT LABORATORY DATA

DATA Lab Test #1

DATA Lab Test #2

DATA Lab Test #3

Lab Test #4

Rationale of abnormal results

Results

Rationale of abnormal results

Results

Rationale of abnormal results

Rationale of abnormal results

MEDICATION NAME

TRADE/GENERIC

DOSAGE ORDERE D

TIMES ADMINISTE RED

DOSE ROUTE

RATIONAL E FOR ADMINIST ERING

THERAPEUTIC RANGE FOR AGE/WEIGHT

NURSING IMPLICATIONS

NURSING DIAGNOSES

LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY)

DESCRIBE RATIONALE FOR PRIORITY ORDER

UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE

(Reference)

ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE

NURSING DIAGNOSIS

PLAN OUTCOME

CRITERIA (CLIENT CENTERED)

INTERVENTIONS (NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

Include subjective and

objective components.

Assess physiological, psychosocial, developmental, cultural and spiritual dimensions.

Use a NANDA

diagnosis which has three (3) parts:

•Part I: NANDA statement of nursing problem " Alternation in nutrition: Less than body requirements"

•Part 2: relating to a nursing etiology: " relating to inadequate nutritional intake"

•Part 3: manifested by the assessed signs and symptoms: " manifested by low body weight and emaciation."

State the overall plan

as client centered, e.g.,:

•" The client will…"

Relate the plan to the nursing diagnosis:

Make the

interventions nurse centered.

Indicate what the nurse will do to assist the client in achieving the outcome criteria, e.g.,

· The nurse will…"

State frequency/time

/amount so any nurse can carry out the plan:

1) Document all food intake for 3 days.

2) Determine and make available client's favorite foods by day 2.

3) etc.

State the principle or

scientific rationale for the nursing intervention(s).

Include the reference for the rationale.

Look at the outcome

criteria.

State whether the client achieved the outcome criteria, e.g.,

· Subjective

Document client's exact words relevant to the diagnosis.

•." have adequate nutritional intake"

" The client gained 2

lbs within the past 7 days…"

"I'm not hungry"

· Objective

Document data that is measurable, specific, and relevant to the nursing diagnosis.

"Weight = 48 Kg" "Lack of subcutaneous fat"

Indicate a measurable outcome criteria by including time frame/amount/range:

•" as evidenced by…"

1) the ability to create a balanced meal plan by day (7).

NOTE:

If the outcome criteria was not achieved or only partially achieved, the nurse needs to go back to the beginning, e.g., the "assessment" and make revisions or changes as necessary.

2) gaining 1-2 lbs/wk until FDA recommended weight is achieved.

(3) etc.

ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE

NURSING DIAGNOSIS

PLAN OUTCOME

CRITERIA (CLIENT CENTERED)

INTERVENTIONS (NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE

NURSING DIAGNOSIS

PLAN OUTCOME

CRITERIA (CLIENT CENTERED)

INTERVENTIONS (NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

ASSOCIATE SCIENCE IN NURSING

CLINICAL WORKSHEET: MATERNITY NURSING PROCESS CARE PLAN

STUDENT NAME

DATE

Client Initials

Culture/Ethnicity

Support System

Unit

Room/Bed

Religion

Age

Sex

Language

Pre-preg Wt

Pre-preg Ht

Marital Status

Children & Ages

Current Wt

Current Ht

Occupation

G

T

P

A

L

Health Insurance

Current Work Status

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