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M / F
Age:______
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FC /
DNR
Allergy:
Y / N
Ht:_______
_
Wt:_______
_
Diet:
______
Activity:
____
Anticipate
d
Discharge
Date
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Admission
Date:
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M / F
Age:______
_
FC /
DNR
Allergy:
Y / N
Ht:_______
_
Wt:_______
_
Diet:
______
Activity:
____
Anticipate
d
Discharge
Date
______
Advancing Clinical Practice: Nursing Process Worksheet Page 2 of 2
Nursing Dx: Planning Goals: Interventions: What specific interventions Educate: What will you teach the Medication: Assess the client’s
Determine priority Define (1) outcome are implemented to achieve each desired client about their procedures, tests, response to prescribed medication.
problems criteria statement for outcome? exams, meds and disease process?
experienced by the each problem. Evaluation: How does each
client (list top 3). Special considerations: Measures medication change pathology of disease
Evaluation: Did the Evaluation: Were Evaluation: Assess response to nursing taken to promote infection control and for which it is prescribed?
problems resolve or goals met or revised? care. Were interventions effective or to provide safe, therapeutic care.
change? revised?
1. 1. 1. Teach: Meds:
2. 2. 2.
3. 3. 3. Special
Considerations:
1. 1. 1. Teach: Meds:
2. 2. 2.
3. 3. 3. Special
Considerations: