NUR 456 NCP <\/p>\n
Student: ________________________________________<\/p>\n
Clients Initials: __________ Age: ________<\/p>\n
Date of Care: _________________<\/p>\n
Hampton University<\/p>\n
School of Nursing<\/p>\n
College of Virginia Beach<\/p>\n
Nursing Process<\/p>\n
Nursing 456 Data Collection Form<\/p>\n
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.<\/p>\n
1. DEMOGRAPHICS: (Initials, race, ethnicity, gender, cultural concerns religious preference, marital status, employment, education level, etc.)<\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
______________________________________________________________________________________________________________________________<\/p>\n
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.)<\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
______________________________________________________________________________________________________________________________<\/p>\n
3. FAMILY MEMBERS AND HISTORY OF DISEASE (Include & attach genogram): <\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
______________________________________________________________________________________________________________________________<\/p>\n
4. CLIENT INTERESTS AND HOBBIES: (Important related to changing lifestyle behaviors, increasing motivation and comfort.)<\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
5. ALLERGIES: (include shellfish\/seafood\/iodine, medications with an abnormal response, food in general, external and\/or environmental products.)<\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
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. \u201cClient\u2019s 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)<\/p>\n
Lab Value or Diagnostic Test<\/p>\n
Client Value<\/p>\n
Normal Value or Outcome<\/p>\n
Significance of Value or Outcome<\/p>\n
Intervention<\/p>\n
Example: WBC<\/p>\n
21,000 mm3<\/p>\n
4,000-10,000 mm3<\/p>\n
Developed UTI<\/p>\n
Antibiotics started. Catheter dc\u2019d <\/p>\n
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.<\/p>\n
Medical Diagnosis<\/p>\n
Definition<\/p>\n
Etiology\/ Risk Factors<\/p>\n
Pathophysiology<\/p>\n
Manifestations<\/p>\n
(including pertinent labs and tests)<\/p>\n
Anticipated Needs<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
7. IMMUNIZATIONS: (Include chicken pox, PPD, Flu, Pneumovax, etc.) __________________________________________________________________ ______________________________________________________________________________________________________________________________<\/p>\n
8. HISTORY OF PRESENT ILLNESS ( Brief, in your own words, do not copy from chart):____________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
9. PAST MEDICAL HISTORY: (Utilize H&P, any previous medical records available) Client\/family_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
______________________________________________________________________________________________________________________________<\/p>\n
10. PAST SURGERIES: (Identify type of surgery, why performed, dates). <\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
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.<\/p>\n
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ <\/p>\n
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
16. ADDITIONAL PERTINENT INFORMATION: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/p>\n
MEDICATIONS<\/p>\n
Generic & Trade Name<\/p>\n
Classification<\/p>\n
Action<\/p>\n
Use<\/p>\n
Side Effects<\/p>\n
Usual Adult <\/p>\n
Dose<\/p>\n
Client Education<\/p>\n
Generic & Trade Name<\/p>\n
Classification<\/p>\n
Action<\/p>\n
Use<\/p>\n
Side Effects<\/p>\n
Usual Adult <\/p>\n
Dose<\/p>\n
Client Education<\/p>\n
Significant Drug \/Food or Drug\/Drug Interactions<\/p>\n
Hampton University – School of Nursing – College of Virginia Beach<\/p>\n
Nursing 456 Practicum\/Lab<\/p>\n
DOCUMENTATION OF THE NURSING PROCESS<\/p>\n
INITIALS OF CLIENT:<\/p>\n
STUDENT NAME: <\/p>\n
AGE OF CLIENT:<\/p>\n
SEX:<\/p>\n
DATE OF ACTUAL CLIENT\/FAMILY CARE:<\/p>\n
RACE:<\/p>\n
RELIGION\/Cultural Variables<\/p>\n
1. ASSESSMENT PHASE<\/p>\n
2. DIAGNOSIS PHASE <\/p>\n
3. PLANNING PHASE<\/p>\n
Data Collection<\/p>\n
Significant Client Information<\/p>\n
Subjective Data<\/p>\n
Objective Data<\/p>\n
Nursing Diagnosis Statement<\/p>\n
NANDA<\/p>\n
RELATED TO <\/p>\n
Physiologic\/Psychologic <\/p>\n
Cause<\/p>\n
*not the medical diagnosis<\/p>\n
AEB<\/p>\n
Data Interpretation & Data Clustering<\/p>\n
supporting data for actual need identified, defining<\/p>\n
characteristics<\/p>\n
EXPECTED OUTCOMES<\/p>\n
Actual _______<\/p>\n
Risk \/Potential _______<\/p>\n
Priority Rationale:<\/p>\n
_______________________________<\/p>\n
_______________________________<\/p>\n
Long term (broad, general)(Measurable Client behavior with time frame, directly related to nursing diagnosis)<\/p>\n
1.<\/p>\n
Short Term (must be measurable and related to specific nursing diagnosis with client behavioral outcomes)<\/p>\n
1.<\/p>\n
3. PLANNING PHASE<\/p>\n
4. IMPLEMENTATION PHASE<\/p>\n
5. EVALUATION PHASE<\/p>\n
NURSING ORDERS for the SPECIFIED NURSING DIAGNOSIS<\/p>\n
RATIONALE<\/p>\n
Cite author, source, year, page for each<\/p>\n
(If I . . ., then . . . , because . . . )<\/p>\n
What you implemented per your plan, written as nursing notes documentation<\/p>\n
EVALUATION of CLIENT OUTCOMES<\/p>\n
Nursing Observations:<\/p>\n
The Nurse will assess, observe, monitor<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Nursing Actions:<\/p>\n
The Nurse will <\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
4.<\/p>\n
5.<\/p>\n
Client\/Family Teaching\/Collaboration<\/p>\n
The Nurse will teach\/Collaborate with<\/p>\n
1.<\/p>\n
2.<\/p>\n
.<\/p>\n
.<\/p>\n
5.<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
4.<\/p>\n
.<\/p>\n
1<\/p>\n
2<\/p>\n
3<\/p>\n
4<\/p>\n
5<\/p>\n
6.<\/p>\n
7.<\/p>\n
LONG TERM OUTCOME<\/p>\n
Met ____ Partially met _____ Not Met ____<\/p>\n
Determining criteria re: client outcome<\/p>\n
SHORT TERM OUTCOMES<\/p>\n
Met ____ Partially met _____ Not Met ____<\/p>\n
Determining criteria re: client outcome<\/p>\n
1. <\/p>\n
Hampton University – School of Nursing – College of Virginia Beach<\/p>\n
Nursing 456 Practicum\/Lab<\/p>\n
DOCUMENTATION OF THE NURSING PROCESS<\/p>\n
INITIALS OF CLIENT:<\/p>\n
STUDENT NAME: <\/p>\n
AGE OF CLIENT:<\/p>\n
SEX:<\/p>\n
DATE OF ACTUAL CLIENT\/FAMILY CARE:<\/p>\n
RACE:<\/p>\n
RELIGION\/Cultural Variables<\/p>\n
1. ASSESSMENT PHASE<\/p>\n
2. DIAGNOSIS PHASE <\/p>\n
3. PLANNING PHASE<\/p>\n
Data Collection<\/p>\n
Significant Client Information<\/p>\n
Subjective Data<\/p>\n
Objective Data<\/p>\n
Nursing Diagnosis Statement<\/p>\n
NANDA<\/p>\n
RELATED TO <\/p>\n
Physiologic\/Psychologic <\/p>\n
Cause<\/p>\n
*not the medical diagnosis<\/p>\n
AEB<\/p>\n
Data Interpretation & Data Clustering<\/p>\n
supporting data for actual need identified, defining<\/p>\n
characteristics<\/p>\n
EXPECTED OUTCOMES<\/p>\n
Actual _______<\/p>\n
Risk \/Potential _______<\/p>\n
Priority Rationale:<\/p>\n
_______________________________<\/p>\n
_______________________________<\/p>\n
Long term (broad, general)(Measurable Client behavior with time frame, directly related to nursing diagnosis)<\/p>\n
1.<\/p>\n
Short Term (must be measurable and related to specific nursing diagnosis with client behavioral outcomes)<\/p>\n
1.<\/p>\n
3. PLANNING PHASE<\/p>\n
4. IMPLEMENTATION PHASE<\/p>\n
5. EVALUATION PHASE<\/p>\n
NURSING ORDERS for the SPECIFIED NURSING DIAGNOSIS<\/p>\n
RATIONALE<\/p>\n
Cite author, source, year, page for each<\/p>\n
(If I . . ., then . . . , because . . . )<\/p>\n
What you implemented per your plan, written as nursing notes documentation<\/p>\n
EVALUATION of CLIENT OUTCOMES<\/p>\n
Nursing Observations:<\/p>\n
The Nurse will assess, observe, monitor<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
Nursing Actions:<\/p>\n
The Nurse will <\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
4.<\/p>\n
5.<\/p>\n
Client\/Family Teaching\/Collaboration<\/p>\n
The Nurse will teach\/Collaborate with<\/p>\n
1.<\/p>\n
2.<\/p>\n
.<\/p>\n
.<\/p>\n
5.<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
4.<\/p>\n
.<\/p>\n
1<\/p>\n
2<\/p>\n
3<\/p>\n
4<\/p>\n
5<\/p>\n
6.<\/p>\n
7.<\/p>\n
LONG TERM OUTCOME<\/p>\n
Met ____ Partially met _____ Not Met ____<\/p>\n
Determining criteria re: client outcome<\/p>\n
SHORT TERM OUTCOMES<\/p>\n
Met ____ Partially met _____ Not Met ____<\/p>\n
Determining criteria re: client outcome<\/p>\n
1. <\/p>\n
HAMPTON UNIVERSITY<\/p>\n
College of Virginia Beach<\/p>\n
Patient Teaching Plan<\/p>\n
Knowledge Deficit ______________________________ related to _________________________________ as evidenced by__________<\/p>\n
_____________________________________________________________________________________________________________________________<\/p>\n
LEARNING <\/p>\n
OBJECTIVES<\/p>\n
CONTENT <\/p>\n
OUTLINE<\/p>\n
TIME <\/p>\n
ALLOCATION<\/p>\n
TEACHING METHOD<\/p>\n
By the completion of the teaching session the client will <\/p>\n
Cognitive (Knowledge\/Describe\/Explain)<\/p>\n
1.<\/p>\n
Affective (Valuing\/Importance)<\/p>\n
1.<\/p>\n
Psychomotor (Perform\/Demonstrate)<\/p>\n
1.<\/p>\n
(this is a topical outline of what will be discussed)<\/p>\n
(must be realistic)<\/p>\n
(what strategies will you utilize)<\/p>\n
REFERENCES<\/p>\n
(APA Format)<\/p>\n
2<\/p>\n","protected":false},"excerpt":{"rendered":"
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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10],"class_list":["post-79164","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/79164","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=79164"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/79164\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=79164"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=79164"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=79164"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}