November 11, 2022

CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN

I need 2 nurse care plan, one for maternity and one for Pediatric, to be done by Friday 11/11/2023 by 5:00 PM, using the 2 formats attached, please only contact me if you are able to get it done on time.

CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN

STUDENT NAME DATE

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:

( 10 )

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

INTRAVENOUS SOLUTION #1

Type

CC/HR gtts/min

Additives:

Rationale for solution –

INTRAVENOUS SOLUTION #2

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