FLORIDA INTERNATIONAL UNIVERSITY

Nicole Wertheim College of Nursing and Health Sciences

CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN

STUDENT NAME ___________________________________________________________ DATE __________________________

Social Determinants of Health: This header

can be placed above occupation. It includes
occupation, health insurance, current work
status, etc.
Unit Room/Bed Religion Support system

Age Sex Language

Weight Height BMI Marital status

Current medical diagnosis Occupation Siblings

Health insurance Name of significant other/primary caregiver

Current work status

Highest grade completed Genogram: Use back of page

Alcohol/Smoking/ Drug use/Sexual and

Reproductive health

Diagnostic Data and Results:

Surgical procedures (current and past):

Past Health History:

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History of Present Illness:

Health Assessment

Physical Assessment:
HEENT:

NEURO:

CV:

RESP:

GI:

GU:

MUSCULOSKELETAL:

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INTEG:

ENDOCRINE:

HEMATOLOGIC:

Pathophysiology (please write in your own words) – Cite References in APA format Baseline and current vital signs/Frequency
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______________________________________________________________________________ Allergies/Side effects
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______________________________________________________________________________ Diet with rationale
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______________________________________________________________________________ Activity order
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______________________________________________________________________________ Limitations/prosthetic devices
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Include all Pertinent Laboratory Include all Pertinent Laboratory Include all Pertinent Laboratory Include all Pertinent Laboratory
Data Results (normal and Data Results (normal and Data Results (normal and Data Results (normal and
abnormal) abnormal) abnormal) abnormal)
PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY
DATA Lab Test #1 DATA Lab Test #2 DATA Lab Test #3 DATA Lab Test #4
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Results_____________________ Results_____________________ Results_____________________ Results_____________________

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Rationale of abnormal results Rationale of abnormal results Rationale of abnormal results Rationale of abnormal results
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___________________________ ___________________________ ___________________________ ___________________________
INTRAVENOUS SOLUTION #1 INTRAVENOUS SOLUTION #2
Type ____________________________________________________ Type ____________________________________________________

ML/HR _________________________ gtts/min __________________ ML/HR _________________________ gtts/min __________________

Additives _________________________________________________ Additives _________________________________________________

Rationale for solution Rationale for solution

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INTRAVENOUS SOLUTION #3 INTRAVENOUS SOLUTION #4

Type ____________________________________________________ Type ____________________________________________________

ML/HR _________________________ gtts/min __________________ ML/HR _________________________ gtts/min __________________

Additives _________________________________________________ Additives _________________________________________________

Rationale for solution Rationale for solution

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MEDICATION DOSE / TIMES RATIONALE FOR THERAPEUTIC NURSING IMPLICATIONS CITATIONS
NAME ROUTE ADMINISTERED ADMINISTERING RANGE FOR Required Patient Education
BRAND/GENERIC ORDERED AGE/WEIGHT If
CLASSIFICATION Applicable

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MEDICATION DOSE / TIMES RATIONALE FOR THERAPEUTIC NURSING IMPLICATIONS CITATIONS
NAME ROUTE ADMINISTERED ADMINISTERING RANGE FOR Required Patient Education
BRAND/GENERIC ORDERED AGE/WEIGHT If
CLASSIFICATION Applicable

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NURSING THEORIST CITE REFERENCES

NURSING DIAGNOSES - NANDA DESCRIBE RATIONALE FOR PRIORITY ORDER

LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY) UTILIZE THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE

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 SAMPLE DIRECTION PAGE: Do not leave in when turning care plan into Faculty
ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION
SUBJECTIVE/ NANDA OUTCOME CRITERIA (NURSE CENTERED) INTERVENTIONS
OBJECTIVE/ (CLIENT CENTERED) Cite References
CONTRIBUTING Must flow from Diagnosis
FACTORS and be individualized
Include subjective Use a NANDA State the overall plan as Make the State the principle or Look at the outcome criteria.
and objective diagnosis which has client centered, e.g.,: interventions nurse scientific rationale for
components. three (3) parts: centered. the nursing State whether the client
•"The client will..." intervention(s). achieved the outcome criteria,
Assess •Part I: NANDA Indicate what the e.g.,
physiological, statement of nursing Relate the plan to the nurse will do to assist Include the reference
psychosocial, problem nursing diagnosis: the client in achieving for the rationale. "The client gained 2 lbs within
developmental, "Alternation in the outcome criteria, the past 7 days..."
cultural and nutrition: Less than e.g.,
spiritual body requirements" •."have adequate NOTE:
dimensions. nutritional intake" •The nurse will..." If the outcome criteria was not
achieved or only partially
•Subjective •Part 2: relating to a Indicate a measurable State frequency/time achieved, the nurse needs to go
Document client's nursing etiology: outcome criteria by /amount so any nurse back to the beginning, e.g., the
exact words "relating to including time can carry out the "assessment" and make
relevant to the inadequate nutritional frame/amount/range: plan: revisions or changes as
diagnosis. intake" necessary.
1) Document all food
"I'm not hungry" •"as evidenced by..." intake for 3 days.
•Part 3: manifested by
•Objective the assessed signs 1) the ability to create a 2) Determine and
Document data that and symptoms: balanced meal plan by make available
is measurable, "manifested by low day (7). client's favorite foods
specific, and body weight and by day 2.
relevant to the emaciation." 2) gaining 1-2 lbs/wk
nursing diagnosis. until FDA recommended 3) etc.
weight is achieved.
"Weight = 48 Kg"
"Lack of (3) etc.
subcutaneous fat"

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 ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION
SUBJECTIVE/ NANDA (North OUTCOME CRITERIA (CLIENT (NURSE CENTERED) INTERVENTIONS
OBJECTIVE/ American Nursing CENTERED) Cite References
CONTRIBUTING Diagnosis Must flow from Diagnosis and be
FACTORS Association) individualized

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ASSESSMENT DATA NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE FOR EVALUATION
SUBJECTIVE/ NANDA (North OUTCOME CRITERIA (CLIENT (NURSE CENTERED) INTERVENTIONS
OBJECTIVE/ American Nursing CENTERED) Cite References (APA)
CONTRIBUTING FACTORS Diagnosis Must flow from Diagnosis and be
Association) individualized

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Discharge Plan / Patient Teaching

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