Assessment – Flow sheet & narrative. Nursing flow sheet & PIE. Medications.
Knowledge of drugs. Calculation and administration of drugs. Documentation.
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WEEKLY PROGRESS SHEET DATE:___________ STUDENT:________________________ INSTRUCTOR EVALUATION
LOCATION:_________ STUDENT COMMENTS (after instructor’s comments)
Preparation for clinical Dress, hygiene, supplies Weekly care plan Medication sheets Daily plan of care Nursing Care Plan Segments done on time Maslow list Prioritized list Outcome statements Interventions Evaluations Documentation Assessment – Flow sheet & narrative Nursing flow sheet & PIE Medications Knowledge of drugs Calculation and administration of drugs Documentation Clinical Skills Performance Communication: with client, staff and instructors Safety Confidentiality Professional conduct Follows policies and procedures of nursing program and facilities; cost containment (DELC-101) Clinical point tool: ________________
*This page will be attached to the weekly care plan by Tuesday at 0640. Failure to do so will result in 5 points being taken off the weekly care plan grade. Instructor signature: _____________________________________________ Date I have reviewed the above comments written by the instructor. (Sign after reading comments) Student signature: ______________________________________________ Date
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Name:_________________________________________Date______________ Grade Sheet for the Weekly Care Plan – VNSG1360 Fall I.
Demographic Data ......................................................................... (1)__________
II.
Doctors Orders (5) (Must be updated daily) A. Diet & Rationale .................................................................... (1)__________ B. Activity Level ......................................................................... (1)__________ C. Medications ........................................................................... (1)__________ D. Treatments ............................................................................ (1)__________ E. Lab & Test............................................................................. (1)__________
III.
Medical Diagnosis Information ....................................................... (2)__________
IV.
Medication Sheet (includes master sheet & client specific drug sheet(5)__________
V.
Plan of Care (Must be updated daily) Must contain: V/S, data for early assessment, diet, S/S of medical diagnosis, treatments, lab & diagnostic tests and bedside nursing care ........................................................ (6)__________
VI.
Nursing Assessment- Flow sheet & Narrative..…………………….. (4)__________ Nursing Flow sheet & PIE Charting ............................................. (4)__________
VII.
Diagnostic Tests ............................................................................. (3)__________
VIII. *Maslow ............................................................................... ….. (16)__________ IX
*Prioritized Nursing Diagnoses List………………………………… (4)__________
X.
*Nursing Process (50) A. Nursing Diagnoses B. Outcome Statements C. Interventions D. Evaluations
(15) _________ (10) _________ (20) _________ (5) _________
Total ............................................................................................. (100) _________ There is one re-accomplishment allowed for critical components (*) for the first care plan only. Only the grade on the critical components * can be improved. Five (5) points per page will be deducted for incorrect, blank or having missing pages.
Page 3 HOWARD COLLEGE VN PROGRAM NURSING CARE PLAN 2013 Due Tuesday AM 0640 Attach weekly progress sheet and grade sheet for the Weekly Care Plan to the front Allergies: Medical Diagnosis: I. Name: Cl. Initials: Ht: Rm# Age: Date of Admission: Instructor
Wt: Sex:
Medical Hx: Surg. Procedure/date:
Date of Care:
II.
Doctor’s Orders (Must be updated daily or indicate no new orders) (NC-3) Date of Diet & Rationale: orders written Activity level:
Medications to include name, dose, route, frequency:
Treatments
Diagnostic tests
Classification
MDS pg #
Page 4 Due Tuesday AM 0640 III. Medical diagnosis definition and nursing care for this medical diagnosis, with reference and page numbers. 1. Medical diagnosis definition: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Textbook S& S: Client S&S: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Nursing care: _________________________________________________________________
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________
*********************************************
2. Medical diagnosis definition: __________________________________________________________________________________ __________________________________________________________________________________ Textbook S & S: Client S&S: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Nursing Care: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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Due Tuesday AM 0640
IV. HOWARD COLLEGE VOCATIONAL NURSING PROGRAM DRUG SHEET NAME: ________________________________ Medication generic (trade)
Dose, Route, Freq
Classification
Therapeutic Actions
2-3 Major Adverse Effects, Any Contraindications
Nursing Implications
Page 6 V.
DAILY PLAN OF CARE
DATE: Day 1: Due Tuesday AM 0640 Please number your entries, one per line 1.
V/S, assessment, AM care, linen change
________________________________________ ____________________________________________
___ _______________________
_________________ Day 2: Due Wednesday AM 0640 Continue those needed from above by number only. Do not rewrite the sentence. Add anything new, number it and write only one per line
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VI. Nurse’s Documentation- Done for each day that you cared for a client. (DEC-6,130) Document date and time. Use medical terminology. Use the assessment flow sheet to document the assessment. Using the assessment flow sheet as a guide, write a full head to toe assessment using a narrative form of writing. Using the Nursing check sheet address routine care, safety, VS, I & O, diet etc. PIE charting using your Prioritized Nursing Diagnoses List Tuesday notes due Wednesday 0640; Wednesday notes due Friday 0800. DATE _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
TIME _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Page 8 Continued DATE _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
TIME _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Page 9 Due Friday AM 0800
VII. INSTRUCTIONS FOR THE DIAGNOSTIC SHEET
DATE:
This is the date the test was done
TEST NAME & ABBREVIATION:
Write the test name and abbreviation
SOURCE:
Source refers to the portion of the body, which the test specimen was taken. Example: blood, urine, spinal fluid, would culture, etc.
NORMAL VALUES:
Write in normal values for your client’s age and sex. This is obtained from the book or from the client’s lab sheet
CLIENT VALUES:
Write the client values
↑ OR ↓ OR N
The arrows indicate that your client’s values are above or below normal. If the value is normal, place “N” in the column
CLINCIAL SIGNIFICANCE OF ABNORMAL LEVEL;
On abnormal test values, write the reason the value is significant to the client’s diagnosis
You may put more than one test on a sheet but skip a line between each. Write legibly. Remember this includes all diagnostic tests such as lab, x-ray, cystoscopy, etc. Each week do lab sheet on the abnormal results pertaining to your client. When a CBC is ordered, only the following areas: WBC, RBC, Hgb, Hct, Platelets need to be included. If there are duplicate test results, eg. H & H daily, include the client’s previous values along with their current client values.
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DIAGNOSTIC DIAGNOSTICTESTS TEST VII. Diagnostic Test - Due Friday with rest of care plan Refer to Master Diagnostic Sheet. Additional Abnormal Lab Values Must be Researched & Added to this Diagnostic Sheet
Test Name & Abbreviation
Source
Clients Values with Dates
Normal Values
or Date
Date
Date
Date
Date
Date
Clinical Significance of the Abnormal Level to the Client
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DIAGNOSTIC DIAGNOSTICTESTS TEST
VII. (B) Diagnostic Test - Due Friday with the rest of the care plan XRAY, MRI, CT, Ultrasound, Cardiac Cath, Stress Testing, EEG, ECG
Date
Test Name & Abbreviation
Normal Findings
Diagnostic Findings
Clinical Significance of the Abnormal Finding to the Client
Page 12 VIII. Maslow Hierarchy of Human Needs (DEC-45A) Due Wednesday at 0640 Maslow’s Hierarchy
Yes Or No
List client data (subj. & obj.) that supports presence of a problem. Data should be similar to defining characteristics in the Diagnoses Book
Physiological Needs S: O: Actual Dx: R/T AEB Risk Dx R/T Temperature
S: O: Actual Dx: R/TAEB Risk Dx
Nutrition
S O Actual Dx R/T AEB Risk Dx R/T
Fluids
S O Actual Dx R/T AEB Risk Dx R/T
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Maslow’s Hierarchy Elimination – Bowel
Yes Or No
List client data (subj. & obj.) that supports presence of a problem. Data should be similar to defining characteristics in the Diagnoses Book
S O Actual Dx RT AEB Risk Dx R/T
Elimination – Urinary
S O Actual Dx R/T AEB Risk Dx R/T
Rest & Sleep
S: O:
Pain Avoidance
Actual Dx: R/T AEB S: O:
Sexuality
Actual Dx: R/T AEB S O Actual Dx
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Maslow’s Hierarchy Stimulation
Yes Or No
List client data (subj. & obj.) that supports presence of a problem. Data should be similar to defining characteristics in the Diagnoses Book
S: O: Actual Dx: R/T AEB Risk Dx R/T
Physical
S O Actual Dx R/T AEB Risk Dx: R/T
Psychosocial Needs Psychological Safety
S: O: Actual Dx: R/T AEB Risk Dx R/T
Love & Belonging
S: O: Actual Dx: R/T AEB Risk Dx: R/T
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Maslow’s Hierarchy Spiritual
Yes Or No
List client data (subj. & obj.) that supports lack of or presence of a problem. Data should be similar to defining characteristics
S O Actual Dx R/T AEB Risk Dx R/T
Esteem/Self Esteem
S O Actual Dx R/T AEB Risk Dx R/T
SelfActualization
S O Actual Dx R/T AEB
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IX Prioritized Nursing Diagnoses List: Due Wednesday at 0640 (DEC 45A) Write the nursing diagnosis in order of Maslow as listed on the previous pages. Write the “actual” diagnoses, then the “risk” diagnoses. Choose only from the “actual” list for your landscape pages. Write the diagnosis statement exactly as you have written it on the previous pages. Number
Actual 1 2 3 4 5 6 7 8 9 10 11 12 Risk 1 2 3 4 5 6
Diagnosis name
Related to
As evidenced by
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X. Columns A, B, C & D due Friday 0800 Nursing diagnoses: Outcome statement: 3 physical (3 pts each) 1 per Dx (2 pts each) 1.Dx.
C. Nursing Interventions with a rationale: (2 pts each) 1.
D. Evaluation of outcome ( 1 pt each) Met Unmet. Reason why met or unmet:
R/T 2. AEB
2.Dx.-
Met.
Unmet
1. Reason why met or unmet: R/T 2. AEB -
3.Dx.
Met
Unmet.
1. Reason why met or unmet: R/T
AEB
2.
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X. Columns A, B,C & D due Friday 0800 Nursing diagnoses: Outcome statement: 2 psychosocial (3 pts each) 1 per Dx (2 pts each) 4.Dx.
C. Nursing Interventions with a rationale: (2 pts each) 1.
D. Evaluation of outcome ( 1 pt each) Met. Unmet Reason why met or unmet:
R/T 2. AEB
5.Dx.
1.
Met
Unmet
Reason why met or unmet: R/T 2. AEB
THE STUDENT MUST CLEAR USING A DIAGNOSIS FROM THE SAME AREA WITH THE INSTRUCTOR. SELF- CARE DEFICITS FROM THE PSYCHOSOCIAL AREA (ESTEEM/SELF-ESTEEM) CANNOT BE WRITTEN UP UNLESS IT IS THE ONLY OTHER DIAGNOSIS LEFT AND IT HAS BEEN CLEARED WITH THE INSTRUCTOR
