COMMUNITY COLLEGE DEPARTMENT OF NURSING CLINICAL ASSESSMENT TOOL Subjective Data (Basic Conditioning Factors) Student: Date of Care: 10/03/09 Patient’s Initials: P. V. Age: 37 Room #: 3114 Bed 1 Allergies: Food: NKA Gender: F Medications: NKA Environmental: NKA Admitting Diagnosis: Pancreatitis Developmental Stage (Erickson and Havinghurst): (List Developmental stage and tasks‚ assess each task) 1. Selecting a mate: Although patient
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I. SAFE AND QUALITY NURSING CARE CORE COMPETENCY 1: Demonstrate knowledge based on health/illness status of individual/ groups Indicators : ○ Identifies health needs of patients/groups ○ Explains patient/group status CORE COMPETENCY 2: Provides sound decision making in care of individual/groups considering their beliefs‚ values Indicators : ○ Problem identification ○ Data gathering related to problem ○ Data analysis ○ Selection appropriate action ○ Monitor progress of action
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occurring in the EHR the physicians tend to only address the abnormal findings within the assessment / treatment. In other ways it is not helpful to nurses an example is “a patient stated she had a hysterectomy and when the nurse goes to type in in a template pops-up and ask what kind of hysterectomy and unless you know specifically it is difficult to choose due to it having a code attached to it. The risk of any fields auto-populating can cause documentation becoming overlooked
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1 Chapter c0001 1 Nursing knowledge and practice Maggie Mallik‚ Carol Hall and David Howard KEY ISSUES s0005 u0190 u0195 u0200 u0205 s0010 u0210 u0215 u0220 u0225 u0230 u0235 u0240 s0015 u0245 u0250 u0255 s0020 u0260 u0265 INTRODUCTION SUBJECT KNOWLEDGE l Definitions‚ theories and models of nursing l Role and image of the nurse l People as recipients of nursing care l Contexts for delivering nursing care Nursing care is provided for people with widely
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RN Program CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN NURSERY STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/Nursery CLINICAL DATE: 01/20/15 PATIENT INTIALS: F.P. AGE: 9 days Sex: M RELIGION/CULTURE: Not documented MATERNAL AND LABOR HISTORY: Mother was admitted to hospital on 01/09/15 for labor induction at 39 weeks and 4 days. Active labor began at 1015. F.P. was born at 1837
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PN 0004C Weekly Clinical Planning Sheet Student Name: S.H Care plan #5 Patient Initials: t.l Age/Sex: 73/f Allergies: Potassium Nurse on Duty: Regin Admission Date: 06/29/2013 Admitting Physician: Dr. Cole Consulting physician: Code status: Hospice‚ dnr Activity Level: As tolerated Diet: nectar thick/puree Patient History and Diagnoses: primary
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Myers‚ 2011). Coronary Artery Disease (CAD) is one of these clinical conditions that affect approximately 13 million people (Rimmerman‚ 2011). Because coronary diseases are the leading cause of death in men and women‚ nurses need to be involved in the care and education of people with or without CAD. Prevention is the best cure. Nurses play an important role in the treatment of CAD by offering and supplying comfort for anxiety and pain‚ minimizing symptoms and side effects‚ educating patients on the
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FLORIDA INTERNATIONAL UNIVERSITY COLLEGE OF HEALTH AND URBAN AFFAIRS SCHOOL OF NURSING CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN STUDENT NAME DATE |Client Initials A.R |Culture/Ethnicity White |Support system Mother‚ Father | |Unit Telemetry Room/Bed 478D |Religion Catholic |
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CARE PLAN Bipolar Disorder‚ Manic Episode [pic] Risk for Other-Directed Violence At risk for behaviors in which an individual demonstrates that he or she can be physically‚ emotionally‚ and/or sexually harmful to others. RISK FACTORS • Restlessness • Hyperactivity • Agitation • Hostile behavior • Threatened or actual aggression toward self or others • Low self-esteem EXPECTED OUTCOMES Immediate The client will • Be safe and free from injury throughout hospitalization
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Psychiatric Clinical Nursing Assessment Jennifer Stokes Daytona State College Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health‚ fear of physical illness‚ hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐
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