NUR 456 NCP
Student: ________________________________________
Clients Initials: __________ Age: ________
Date of Care: _________________
Hampton University
School of Nursing
College of Virginia Beach
Nursing Process
Nursing 456 Data Collection Form
Instructions: Submit a comprehensive plan on the client to include physiologic, psychologic, economic, spiritual, social issues for the client. There are 2 nursing care plan forms within this document; your client however may need more based on your comprehensive patient assessment.
1. DEMOGRAPHICS: (Initials, race, ethnicity, gender, cultural concerns religious preference, marital status, employment, education level, etc.)
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2. DEVELOPMENTAL STAGE AND AGE: (Include expected stage based on age vs. the actual age demonstrated. Also data to justify which end of the stage the client currently demonstrates.)
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3. FAMILY MEMBERS AND HISTORY OF DISEASE (Include & attach genogram):
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4. CLIENT INTERESTS AND HOBBIES: (Important related to changing lifestyle behaviors, increasing motivation and comfort.)
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5. ALLERGIES: (include shellfish/seafood/iodine, medications with an abnormal response, food in general, external and/or environmental products.)
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6. LABORATORY and DIAGNOSTIC OUTCOMES: (List actual lab values with ranges and diagnostic studies with interpretation of results {WNL is not acceptable}). List only those that are abnormal, unexpected or directly impact client needs or health status. When Clients have been hospitalized over a period of time, you may list their lab values, based upon ranges, i.e. “Client’s WBC ranged from ____ to ____ WBC normal range is ______. Identify the significance of any abnormal laboratory value or diagnostic test. Significance relates to why the abnormality has occurred. Significance is not designated by the identification of high or low. (If more lines are needed insert another row below the last row)
Lab Value or Diagnostic Test
Client Value
Normal Value or Outcome
Significance of Value or Outcome
Intervention
Example: WBC
21,000 mm3
4,000-10,000 mm3
Developed UTI
Antibiotics started. Catheter dc’d
Textbook Description: Based on the medical diagnoses of your assigned client, describe and/or define each of the following relevant topics. Use your required nursing texts and texts from supporting courses, such as Anatomy and Physiology. Using APA format, cite your source for the information and complete the attached reference page. Additional lines may be added by inserting a row below the last row.
Medical Diagnosis
Definition
Etiology/ Risk Factors
Pathophysiology
Manifestations
(including pertinent labs and tests)
Anticipated Needs
1.
2.
3.
7. IMMUNIZATIONS: (Include chicken pox, PPD, Flu, Pneumovax, etc.) __________________________________________________________________ ______________________________________________________________________________________________________________________________
8. HISTORY OF PRESENT ILLNESS ( Brief, in your own words, do not copy from chart):____________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. PAST MEDICAL HISTORY: (Utilize H&P, any previous medical records available) Client/family_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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10. PAST SURGERIES: (Identify type of surgery, why performed, dates).
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11. PHYSICAL ASSESSMENT: (Write a comprehensive assessment of the client to include: Neuro, EENT, Resp, CVS, GI, GU, Integ, Musc, Pain, Psychosocial, spiritual, etc.). Highlight abnormal findings in your assessment, this will guide the problems you workup in this care plan.
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16. ADDITIONAL PERTINENT INFORMATION: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MEDICATIONS
Generic & Trade Name
Classification
Action
Use
Side Effects
Usual Adult
Dose
Client Education
Generic & Trade Name
Classification
Action
Use
Side Effects
Usual Adult
Dose
Client Education
Significant Drug /Food or Drug/Drug Interactions
Hampton University – School of Nursing – College of Virginia Beach
Nursing 456 Practicum/Lab
DOCUMENTATION OF THE NURSING PROCESS
INITIALS OF CLIENT:
STUDENT NAME:
AGE OF CLIENT:
SEX:
DATE OF ACTUAL CLIENT/FAMILY CARE:
RACE:
RELIGION/Cultural Variables
1. ASSESSMENT PHASE
2. DIAGNOSIS PHASE
3. PLANNING PHASE
Data Collection
Significant Client Information
Subjective Data
Objective Data
Nursing Diagnosis Statement
NANDA
RELATED TO
Physiologic/Psychologic
Cause
*not the medical diagnosis
AEB
Data Interpretation & Data Clustering
supporting data for actual need identified, defining
characteristics
EXPECTED OUTCOMES
Actual _______
Risk /Potential _______
Priority Rationale:
_______________________________
_______________________________
Long term (broad, general)(Measurable Client behavior with time frame, directly related to nursing diagnosis)
1.
Short Term (must be measurable and related to specific nursing diagnosis with client behavioral outcomes)
1.
3. PLANNING PHASE
4. IMPLEMENTATION PHASE
5. EVALUATION PHASE
NURSING ORDERS for the SPECIFIED NURSING DIAGNOSIS
RATIONALE
Cite author, source, year, page for each
(If I . . ., then . . . , because . . . )
What you implemented per your plan, written as nursing notes documentation
EVALUATION of CLIENT OUTCOMES
Nursing Observations:
The Nurse will assess, observe, monitor
1.
2.
3.
Nursing Actions:
The Nurse will
1.
2.
3.
4.
5.
Client/Family Teaching/Collaboration
The Nurse will teach/Collaborate with
1.
2.
.
.
5.
1.
2.
3.
4.
.
1
2
3
4
5
6.
7.
LONG TERM OUTCOME
Met ____ Partially met _____ Not Met ____
Determining criteria re: client outcome
SHORT TERM OUTCOMES
Met ____ Partially met _____ Not Met ____
Determining criteria re: client outcome
1.
Hampton University – School of Nursing – College of Virginia Beach
Nursing 456 Practicum/Lab
DOCUMENTATION OF THE NURSING PROCESS
INITIALS OF CLIENT:
STUDENT NAME:
AGE OF CLIENT:
SEX:
DATE OF ACTUAL CLIENT/FAMILY CARE:
RACE:
RELIGION/Cultural Variables
1. ASSESSMENT PHASE
2. DIAGNOSIS PHASE
3. PLANNING PHASE
Data Collection
Significant Client Information
Subjective Data
Objective Data
Nursing Diagnosis Statement
NANDA
RELATED TO
Physiologic/Psychologic
Cause
*not the medical diagnosis
AEB
Data Interpretation & Data Clustering
supporting data for actual need identified, defining
characteristics
EXPECTED OUTCOMES
Actual _______
Risk /Potential _______
Priority Rationale:
_______________________________
_______________________________
Long term (broad, general)(Measurable Client behavior with time frame, directly related to nursing diagnosis)
1.
Short Term (must be measurable and related to specific nursing diagnosis with client behavioral outcomes)
1.
3. PLANNING PHASE
4. IMPLEMENTATION PHASE
5. EVALUATION PHASE
NURSING ORDERS for the SPECIFIED NURSING DIAGNOSIS
RATIONALE
Cite author, source, year, page for each
(If I . . ., then . . . , because . . . )
What you implemented per your plan, written as nursing notes documentation
EVALUATION of CLIENT OUTCOMES
Nursing Observations:
The Nurse will assess, observe, monitor
1.
2.
3.
Nursing Actions:
The Nurse will
1.
2.
3.
4.
5.
Client/Family Teaching/Collaboration
The Nurse will teach/Collaborate with
1.
2.
.
.
5.
1.
2.
3.
4.
.
1
2
3
4
5
6.
7.
LONG TERM OUTCOME
Met ____ Partially met _____ Not Met ____
Determining criteria re: client outcome
SHORT TERM OUTCOMES
Met ____ Partially met _____ Not Met ____
Determining criteria re: client outcome
1.
HAMPTON UNIVERSITY
College of Virginia Beach
Patient Teaching Plan
Knowledge Deficit ______________________________ related to _________________________________ as evidenced by__________
_____________________________________________________________________________________________________________________________
LEARNING
OBJECTIVES
CONTENT
OUTLINE
TIME
ALLOCATION
TEACHING METHOD
By the completion of the teaching session the client will
Cognitive (Knowledge/Describe/Explain)
1.
Affective (Valuing/Importance)
1.
Psychomotor (Perform/Demonstrate)
1.
(this is a topical outline of what will be discussed)
(must be realistic)
(what strategies will you utilize)
REFERENCES
(APA Format)
2