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
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #1
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Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #2
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Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #3
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Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
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

4/2019
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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