Nursing Process

Instructions:
Each clinical day each student will develop a nursing process outline for one patient of their choice. These are quick writes and should be done throughout the shift and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows:

Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial)
Obj:__________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________
Subj:__________________________________________________________________________________________________________________________________________________________________________________

Nursing Diagnosis (2) Must be prioritized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Etiology (Cause) : as evidenced by (Signs and symptoms) Abnormal Assessment Findings.
(1)__________________________________________________________________________________________________________________________________________________________________________________
(2)__________________________________________________________________________________________________________________________________________________________________________________

Planning (Patient goals) Must be SMART goals
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.)
______________________________________________________________________________________________________________________________________________________________________________________
Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ specific multi-disciplinary team; & Teach
______________________________________________________________________________________________________________________________________________________________________________________

Evaluation (What was the outcome: Goal; Met or Not met or Partially met and 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 NCSBN

Management of Care _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Safety and Infection Control _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Basic Care and Comfort _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Management of Care: providing and directing nursing care that enhances the care delivery set¬ting 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, Handling 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 and Sleep