In depth Form by liaoqinmei

VIEWS: 7 PAGES: 39

									                                                                              Student: ____________              Date:
                                                                                                                 Course: NSG 225
                                                  NURSING PROCESS TOOL
                                                     Patient Care Worksheet

                                                        Patient Information
Pt.’s Initials _______ Rm. # _______ Age                             Gender              Code Status
Diagnosis
                                                                      Admission date ________ Surgery (Rx) date
Surgery                                                               Hospital day ________ Post-Op day ________
                                                                      Doctors
Co-Dx.                                                                Allergies

                                                                      Special needs (HOH, blind, ESL, etc)



                                                  Time Management for the Day
                                  (Include unit routines, nursing actions, treatments, Dr. orders)
Time                        Medications                                             Treatments/Patient Care
0800




0900




1000




1100




1200




Directions: Each section of nursing process tool may be typed or handwritten. In courses with an assessment day, the nursing process
tool must be completed by beginning of first patient care day.
NSG 225 Proc Tool - 08                                            1
                                                  Report (Patient Care Day)
                                            (Nurse, Kardex/Patient Care Summary)
                           Coming On                                                        Going Off

Vital signs                                                      Vital signs

O2 Sat ______%                                                   O2 Sat ______%
O2 _____ L or _____% Type Mask ______                            O2 _____ L or _____% Type Mask ______
Resp. Tx.  Freq. q. ____ hr. prn q ______ hr.                   Resp. Tx.  Freq. q. ____ hr. prn q ______ hr.
  Med. __________________ Time last Tx. ______                     Med. __________________ Time last Tx. ______
ISE q _______ hr. Suction         Trach care                   ISE q _______ hr.      Suction        Trach care 

Weight                                                           Weight
Last shift Intake __________ Output                              Last shift Intake __________ Output
Last BM ______                                                   Last BM ______

Accu _______________                                            Accu _______________

IV: Soln.                          Rate                          IV: Soln.                         Rate
    Site ___________              Tbg. Δ date                        Site ___________             Tbg. Δ date
IV: Soln.                          Rate                          IV: Soln.                         Rate
    Site ___________              Tbg. Δ date                        Site ___________             Tbg. Δ date
Saline Lock: Site                                                Saline Lock: Site

Central line drsg Δ                                             Central line drsg Δ 

Tubes: NG        GT       Suction                             Tubes: NG        GT       Suction 
       Foley  SP cath     Ostomy  Type                               Foley  SP cath     Ostomy  Type
       Chest tube  Suction                                             Chest tube  Suction

Diet                          Fld. Restriction                   Diet                         Fld. Restriction
Tube Fdg.                          Rate                          Tube Fdg.                         Rate
  Residual ______                                                  Residual ______

Telemetry        Rhythm                                         Telemetry      Rhythm

Activity                                                         Activity
TED  SCD  Special bed                                         TED  SCD  Special bed 
PT  Time         OT  Time                                      PT  Time         OT  Time
Restraints  Type                                                Restraints  Type

Wound Care  Dressing/Incision Status                            Wound Care  Dressing/Incision Status
Site          Drains  Type                                      Site          Drains  Type
Order                                                            Order

Pain                                                             Pain
Med given                   Time of last dose                    Med given                  Time of last dose

Labs/diag. studies today                                         Labs/diag. studies today
  Significant results                                              Significant results

Off unit  Time             Purpose                              Off unit  Time            Purpose
Specimens needed                                                 Specimens needed

Isolation  Type               Organism                          Isolation  Type              Organism

Teaching needed                                                  Teaching needed

New Orders                                                       New Orders

Focused Assessment                                               Focused Assessment



NSG 225 Proc Tool - 08                                       2
Narrative Charting (Patient Care Day)

Date/Time




NSG 225 Proc Tool - 08                  3
Directions for Patient Care Worksheet:

1. The patient care worksheet is a guide for daily implementation of patient care and the patient’s plan of care. Its use
   begins in NSG 122. It needs to be with you at all times. It develops and organizes your role as manager of patient care.

2. The patient care worksheet should be used as a worksheet, a reminder sheet, a ready reference for questions. For
   example, you take the patient’s vital signs and won’t remember them, jot them down on the worksheet.

3. The patient care worksheet is divided into four sections.

    Section 1: Patient Information

     Includes facts obtained from the admission sheet and kardex / patient care summary.
     Is completed on assessment day or prior to patient care (when no assessment day).

    Section 2: Daily Time Management

     Organizes doctor’s orders, plan of care, nursing unit routines, and expected nursing actions into an action plan.
     Medication column should list all meds given during the identified times. List name only. Include any hints needed
      related to rates, parameters, etc. Example, Levaquin IVPB (1 hr.) (secondary tubing), Digoxin (HR 100). This sheet
      is NEVER used as the Medication Administration Record at the med cart!
     The Treatment / Patient Care column lists all actions the nurse will do during the identified times. The list includes
      expected actions of a nurse such as getting/giving report, checking labs, assessment, charting, checking new orders,
      etc. The list includes actions from the plan of care such as turn and position under the specific time, cough and deep
      breathe, feeding, etc. And the list includes actions from orders on the kardex / patient care summary such as Accu,
      vitals, feeding tube changes, dressing changes, times for PT or RT, etc.
     Treatment column provides a place to note special interventions for this patient.
     Treatment column is a convenient spot to jot down vital signs, output, etc. if remembering the facts is difficult.
     Is completed prior to patient care day 1.

    Section 3: Report from the Nurse

     Provides an outline to identify what is happening today. Presents a current summary of the patient.
     Provides a format to take report, questions to ask, focus for what needs to be known at the moment. Also provides a
      format for giving report at the end of the clinical day.
     Focused assessment portion refers to breath sounds, pulses, edema, heart sounds, bowel sounds, emotional status,
      orientation, complications, etc. Any change in patient’s condition would be noted here.
     The “going off” section of the report sheet is a good place to jot down vital signs, changes in orders, changes in
      patient condition, etc.
     Is completed from two sources – the nurse and the kardex / patient care summary. Orders, such as O2, diet, activity,
      etc. may be completed from kardex / patient care summary on assessment day and updated while waiting for the
      nurse.

      Section 4: Narrative Charting

     To be used in early courses to write narrative charting before placing on actual patient chart.
     To be used in any course where narrative charting is not part of the clinical day.
4. As a worksheet, all daily changes are noted in the appropriate section. The old statement is crossed through once, and
   the new one entered. For example, activity changes from BR to OOB in chair, Levaquin is DC’d and Zithromax added,
   code status changes from Full to DNRCCA.




NSG 225 Proc Tool - 08                                         4
Directions: No highlighting.
                                                  Assessment Data Base

1. History of Present Illness




    Complications/New Conditions




2. Health History
   Prenatal / Obstetrical / Neonatal / Pertinent newborn history



    Medical




    Surgical




    Psychological & Emotional




                                                 Home Medications
                         Name                 Dose                 Freq.   Ordered in     Has been taking at
                                                                           Hosp. (Y, N)   home? If not, why?
                    Prescription




                 Over the counter




                Herbal/Homeopathic




NSG 225 Proc Tool - 08                                        5
Directions:     Focus on major problems. Limit to one or no more than 2: 2 stressors (NSG 122), 2 medical diagnoses, or 1 medical and 1
                surgical procedure. No highlighting needed. Complete using this form, bulleted format, no paragraphs, no text disc/internet
                printouts.

                                            Medical Diagnosis/Physiological Stressor

Disease/Stressor:                                                         Page #’s in Lewis/Wong:

Definition, pathophysiology of disease/stressor:




Etiology, risk factors:




Clinical manifestations (signs/symptoms):




Lab tests, diagnostic studies:




Multidisciplinary management (specific meds, treatments, surgeries):




Complications specific to this disease/stressor:




NSG 225 Proc Tool - 08                                               6
Directions:     Focus on major problems. Limit to one or no more than 2; 2 stressors (NSG 122), 2 medical diagnoses, or 1 medical and 1
                surgical procedure. No highlighting needed. Complete using this form, bulleted format, no paragraphs, no text disc/internet
                printouts.

                                            Medical Diagnosis/Physiological Stressor

Disease/Stressor:                                                         Page #’s in Lewis/Wong:

Definition, pathophysiology of disease/stressor:




Etiology, risk factors:




Clinical manifestations (signs/symptoms):




Lab tests, diagnostic studies:




Multidisciplinary management (specific meds, treatments, surgeries):




Complications specific to this disease/stressor:




NSG 225 Proc Tool - 08                                               7
Directions:     Complete using bulleted format, no paragraphs. No highlighting.

                                                         Surgical Procedure

Surgery:                                                                  Data Sources:

Definition/description of the surgery (include all pertinent data such as location, body systems affected, etc):




Normal post-operative assessment findings/responses related to surgery in general, and this specific surgery:




Expected post op interventions (ex. drains, meds, tx., activity, etc.):




Possible complications of this surgery with signs and symptoms of the complication:

                Complications                               Signs and Symptoms




NSG 225 Proc Tool - 08                                             8
Directions:     Each medication on the MAR, the infusing IV, and respiratory meds (MDI, nebulizer) must be identified on one of the
                following med or IV pages. Each entry on the med or IV sheets must also have a medication card, preprinted or
                handwritten. Student will be responsible for content on the medication and IV pages plus class, action, side effects, and
                nursing interventions from the med card. If no card available for meds/IV solutions, student must develop a card which
                includes class, action, side effects, interventions. A parameter is the specific assessment finding that indicates whether the
                med is to be given. Parameters are identified from Dr.’s orders, med text, or critical thinking using side effects of the med.
                Examples of parameters would be: lomotil – diarrhea present, give; K-Dur – K+ > 5.0, hold; Toprol – BP < 100/60, hold.

                                                        MEDICATIONS
                          (complete for all meds, all shifts, scheduled and prn, all routes except IV)
Med order = trade and generic name, dose,                                                            Confirmed Identity:
route, administration (ex. bid, 1000-1800)                                                           Checked Allergies:

                                                      Normal                                                          Parameter
              Medication Order                      mg/kg dosing               Reason for this Patient             (when applicable)




NSG 225 Proc Tool - 08                                                9
                                 Normal                                         Parameter
            Medication Order   mg/kg dosing        Reason for this Patient   (when applicable)




NSG 225 Proc Tool - 08                        10
                                                      IV SOLUTIONS AND MEDICATIONS

                                                            CONTINUOUS IV SOLUTIONS                               Number of IV Sites:
                                                                  If infusing with
                 Order:                            Tonicity       another IV, is it          Rate              Reason for this             Parameter
      Solution/Additive/Medication                                  compatible?                                   patient




                                                                     PCA PUMP
                              Compatible
         Medication             with IV            Dose       Lockout      Maximum        Continuous             Reason for this          Parameter
                              connected           Ordered     Interval      4 hour           Rate                   patient
                                 to it?                                      dose




IV System = infusing IV OR Saline lock
                                          MEDICATIONS: INTERMITTENT IV PIGGYBACKS (IVPB)
      Medication/Solution                Normal       IV System      Compatible           Book rate              Reason for this        Parameter
                                         mg/kg          & Site        with IV?               &                      patient
                                         dosing                                           Pump rate
                                                                         Solution
                                                                         y n
                                                                          Additive
                                                                         y n
                                                                         PCA med
                                                                         y n
                                                                         Solution
                                                                         y n
                                                                          Additive
                                                                         y n
                                                                         PCA med
                                                                         y n
                                                                         Solution
                                                                         y n
                                                                          Additive
                                                                         y n
                                                                         PCA med
                                                                         y n

                                                     MEDICATIONS: DIRECT IV PUSH (IVP)
             Order               Normal       IV System        Compat-                                                   Reason for
                                 mg/kg          & Site          ible?             Dilution                Rate           this patient     Parameter
                                 dosing
                                                               Solution       Amount added          Total time
                                                               y n          ____________
                                                                Additive                            Per Min.
                                                               y n          Total ml’s after
                                                               PCA med        diluting              15 sec.
                                                               y n          ____________
                                                               Solution       Amount added          Total time
                                                               y n          ____________
                                                                Additive                            Per Min.
                                                               y n          Total ml’s after
                                                               PCA med        diluting              15 sec.
                                                               y n          ____________
                                                               Solution       Amount added          Total time
                                                               y n          ____________
                                                                Additive                            Per Min.
                                                               y n          Total ml’s after
                                                               PCA med        diluting              15 sec.
                                                               y n          ____________
NSG 225 Proc Tool - 08                                                       11
Directions:         Norms are the reference values from agency, not a text. Norms include the result (number) plus its unit of measurement
                    (Ex. Na+ = 140 mEq/L). Record results of all studies completed, normal and abnormal. Highlight abnormal. Identify the
                    actual result for lab studies and indicate  or  if abnormal. Other is a lab/study not listed but critical.
                    Interventions include assessment (signs/symptoms resulting from the abnormal result), actions because of the
                    signs/symptoms, and actions specific to patient. Example: K+  muscle weakness  provide assistance  IV of NS with
                    20 meq. KCl.

                                                      Laboratory and Diagnostic Studies
                                                          Neurological (Exchanging)
   Laboratory                 Agency                Initial               Current                  Interventions for abnormal result
    Studies                   Norms            Date      Result        Date    Result
                                                      or ?               or ?
CSF analysis

Other:


Diagnostic                        Date                Result                                       Interventions for abnormal result
Procedures
EEG


CT: (Site)


MRI: (Site)


Ultrasound


Other:




                                                          Oxygenation (Exchanging)
   Laboratory                 Agency                Initial               Current                  Interventions for abnormal result
    Studies                   Norms            Date      Result        Date    Result
                                                      or ?               or ?
ABG’s / CBG’s
Room air/O2 L or %                             RA  O2 _______        RA  O2 _______
  pH

  pCO2

  pO2

  O2Sat

  HCO3

Sputum C & S           Date                  Result

RSV culture

Influenza A culture

Pertussis culture

Throat culture

Rapid Strep

Other:




NSG 225 Proc Tool - 08                                                12
                                        Oxygenation (Exchanging) - Continued
Diagnostic                    Date            Result                           Interventions for abnormal result
Procedures
Chest X-Ray


CT / MRI


Bronchoscopy


Sonogram


Pulmonary
Function test

Other:




                                                   Circulation (Exchanging)
   Laboratory              Agency           Initial              Current       Interventions for abnormal result
    Studies                Norms       Date      Result       Date    Result
                                              or ?              or ?
CBC:
   RBC

     Hgb

     HCT

     WBC

     Neutro %

     Segs %

     Bands %

     Baso %

     Lymph %

     Mono %

     Eosino %

     Platelets

     Reticulocyte
     count
Blood cultures &
sensitivity

     ESR

     ANC

Digoxin level

Coag:
    PT

     PTT

Type &              Date             Result
crossmatch &
# units



NSG 225 Proc Tool - 08                                        13
                                     Circulation (Exchanging) Continued
   Laboratory            Agency          Initial             Current       Interventions for abnormal result
    Studies              Norms    Date        Result      Date   Result
                                               or ?           or ?
Electrolytes:
     Na+

      K+

      Cl-

      Ca++

      Mg++

      Phos

Venous CO2

Renal:
    BUN

      Creatinine

Other:


Diagnostic                 Date     Result                                 Interventions for abnormal result
Procedures
Cardiac
Catheterization

Multiple Lead
EKG (ECG)

Echocardiogram


TEE


Doppler Studies
(site)

Other:




                                                Nutrition (Exchanging)
   Laboratory            Agency        Initial               Current       Interventions for abnormal result
    Studies              Norms    Date      Result        Date    Result
                                         or ?               or ?
Glucose:
    FBS
    Hgb A1C

Protein:
    Prealbumin
    Ser. albumin

      Total Protein

Liver:
     Total Bilirubin
       Direct

         Indirect

      AST

      ALT

NSG 225 Proc Tool - 08                                    14
                                             Nutrition (Exchanging) Continued
   Laboratory              Agency            Initial               Current       Interventions for abnormal result
    Studies                Norms      Date        Result        Date    Result
                                                or ?              or ?
      Alkaline
      Phosphatase
      Ammonia

      Hepatitis
        Screen

Other:


Diagnostic                  Date       Result                                    Interventions for abnormal result
Procedures
UGI


Swallowing
Studies


Ultrasound (site)


EGD


pH probe


Other:



                                              Physical Integrity (Exchanging)
   Laboratory              Agency          Initial                 Current       Interventions for abnormal result
    Studies                Norms      Date      Result          Date    Result
                                              or ?                or ?
Therapeutic drug
index: (identify)

Wound C & S

Other:

Pathology           Date            Result
specimen:



                                                  Elimination (Exchanging)
   Laboratory              Agency          Initial                 Current       Interventions for abnormal result
    Studies                Norms      Date      Result          Date    Result
                                              or ?                or ?
Urinalysis:
    RBC
    WBC

      Protein

      Glucose

      Ketones

      pH

      Sp. Gr.

      Bacteria

Urine C & S


NSG 225 Proc Tool - 08                                     15
                                        Elimination (Exchanging) - Continued
     Laboratory            Agency            Initial               Current       Interventions for abnormal result
      Studies              Norms      Date        Result        Date    Result
                                                or ?              or ?
Stool:
    C&S
    C. difficile
      toxin
    Occult blood
    (guaiac)
    SSYC            Date            Result

      ROTO

      O&P

Other:


Diagnostic                  Date       Result                                    Interventions for abnormal result
Procedures
KUB


IVP


Cystoscopy


Abdominal X-Ray


Ultrasound (site)


CT / MRI (site)


Other:




                                                Reproductive (Exchanging)
Diagnostic                 Date       Result                                     Interventions for abnormal result
Procedures
Ultrasound


CT


UCG (pregnancy)

Other:




                                                           Moving
Diagnostic                 Date       Result                                     Interventions for abnormal result
Procedures
X-Ray:
(bone, joint)

CT/MRI (site)


Other:




NSG 225 Proc Tool - 08                                     16
                                                  Choosing
                         Agency
Laboratory               Norms    Date   Result              Interventions for abnormal result
Studies
Blood Alcohol
Level


Lead Level


Tylenol Level


ASA Level


Drug Screen




NSG 225 Proc Tool - 08                            17
Directions:     Answer questions as directed. Respond to each assessment question. Write comments to an assessment
                question if clarification needed. Identify any change that occurs in assessment in column for Day 2. Highlight
                abnormal findings in any column.

                                               Response Pattern Assessment

Date:                                          Date:                                         Date:
Time:                                          Time:                                         Time:
Temp       Pulse         Resp     BP         Temp    Pulse           Resp     BP         Temp    Pulse         Resp       BP


                                NEUROLOGICAL (Exchanging)                                            Changes from Assessment Day
LOC:
   Alert       Lethargic         Comatose        Follows commands         Yes       No 
Pupils:
   Size: R:_____mm               L:_____mm             Equal: 




    Reaction to light: Equal R/L 
    No Reaction R  L           Sluggish R  L       Rapid R  L 
Fontanel:
   Soft        Flat      Depressed         Bulging       Tense 
Head Circumference (if < 1 yr old):
   OFC measurement _______cm                  OFC _____%ile
Infant reflexes present (identify):
Thought Process:
   Orientation:  Person               Place       Time         Situation 
    Attention Span:       Min. _________
    Memory: Short-Term            Long Term 
    Thought process for age:
     Concrete       Formal               Deductive        Abstract 
    Learning disability     Yes       No 
Sensory Function (feeling):         Touch        Temperature 

Grip:    Equal           R Strong  Weak 
                          L Strong  Weak 

Behavior:
   Restless             Combative        Agitated           Calm 
   Arousable             Easily aroused 

Complaints:        Headache           Dizziness 




NSG 225 Proc Tool - 08                                          18
                                       COMMUNICATING                                           Changes from Assessment Day
Primary Language:
    English   Read               Write       Understand 
    Other  ______________________           Interpreter: Yes           No 
    Sign Language 

Speech:
   # of words for age spoken (if < 5 yrs old) ______                % understandable _______
    Sentence structure used for age __________________________
    Sentence structure appropriate for age: Yes                 No 
    Language skills appropriate for age:          Yes           No 
    Speech if over age 5: Clear             Slurred       Unintelligible       Aphasic 
    Vocalizations 
Hearing:
   No deficit                Impaired Hearing                  Aids 
Vision:
    Clear           Loss             Glasses                  Contacts 
Eye Contact:
   Yes            No        Occasionally       Explain: _______________________



                                  OXYGENATION (Exchanging)                                     Changes from Assessment Day

Respiratory Qualities (pattern):
   Rate _____ Normal for age Yes                 No       Normal range for age ___________
    Ease:     Labored             Unlabored 
              Dyspnea        Orthopnea        Apnea           Flaring 
              Cheyne Stokes  Kussmaul                  Grunting         See-Saw 
    Retractions:     Intercostal      Suprasternal  Substernal 
                     Subcostal        Supraclavicular 
    Depth:      Shallow          Deep 
    Symmetrical          Nonsymmetrical 
Gas Exchange:
   Pulse ox _________%            Color ______________________
    Aeration bilateral Yes  No 
    Breath sounds equal bilaterally Yes  No 

    Breath Sounds:   Upper             Lower              Upper         Lower
               Right                              Left

      Clear                                                             

      Crackles                                                          

      Rhonchi                                                           

      Diminished                                                        

      Wheezes             I/E       I/E                I/E           I/E 
      Friction Rub                                                      



NSG 225 Proc Tool - 08                                             19
                                   OXYGENATION (Exchanging)                                  Changes from Assessment Day
Airway:
    Stridor 
    Cough:      None 
         Dry            Moist      Tight        Croupy       Upper Airway Congestion 
         Frequent  Infrequent                Productive       Nonproductive 
    Sputum: None 
         Color _______             Odor              Consistency: Thick       Thin 
Respiratory Aids:  None 
   O2:       NC                  L/M                        % _________
             Mask       ________ %                          Type ______
   ISE level      ml.
    ThAirpy vest Yes  No                     CPT/P&D Yes             No 
    Breathing Treatment: Yes               No 
      Med                                              Frequency
      Peak flow Pre Rx                      Post Rx
    Chest tube: Location ____________ Suction _____ mm              Gravity 
     Drainage (describe) ___________________
     Dressing intact:     Yes         No 

    CPAP                  Bi PAP 

    ETT                   Trach 
    Ventilator            Mode              Rate               O2
     Pressure                         TV ______          PEEP ______

    Mist tent 

Isolation:
    Yes     No           Organism ___________
    Type: Contact       Airborne  Special Airborne                    CF 
           Latex precautions 



                            CIRCULATION (Exchanging)                                         Changes from Assessment Day
Cardiac:
   Heart rate (apical) ________ Normal for age Yes  No 
         Normal range for age ____________

    Heart rhythm:          Regular            Irregular 
    Telemetry rhythm:
    Heart Sounds:
         S1S2       Clear            Distant         Muffled 
         Murmur ________________ Extra:
    BP              Normal for age Yes               No 
         Normal range for age ____________




NSG 225 Proc Tool - 08                                             20
                                    CIRCULATION (Exchanging)                                     Changes from Assessment Day
Peripheral:
    Pulses:
                Strength (D, O, +1, +2, +3)                     Equal          Weaker
      Radial        R ______ L _____                                          R L
      Pedal         R ______ L _____                                          R L
    Capillary Refill ______ sec.
    Temperature of extremities: Equal: Arms Yes  No 
                                       Legs Yes  No 
      Warm RA               LA                  Cool RA  LA 
           RL               LL                       RL  LL 

    Appearance of extremities: R                  L
      Hair absent                                

      Nails thick                                

      Skin dry, scaly                            

      Color: Pink            Pale        Ruddy            Jaundice         Other ________
    Sensation in extremities:                 R                 L
      Absence of feeling                                       

      Heaviness                                                

      Numbness, tingling                                       

    Edema:      Yes  No              Site
      Pitting     1+         2+      3+            4+               Nonpitting 
    Thrombophlebitis:         None           R         L         Bilateral 
      Redness           Warmth           Tenderness              + Homan’s         Edema 
    Vascular access:
      Arterial line  Umbilical (NICU)                      Radial           Other _________
      Venous line  Umbilical (NICU)                           Other _________




NSG 225 Proc Tool - 08                                                    21
                                   HYDRATION (Exchanging)                                             Changes from Assessment Day
Tissue:
    Mucous Membranes:            Moist        Dry 
    Skin Turgor: Rapid             Tenting 
    JVD (older children):        Yes          No 
Fontanel:
   Soft         Flat        Sunken        Raised       Tense 

Fluid Status:
    I&O: Previous day’s 24 hours
      Total Intake ________                       Total Output _______                                Previous 24 hours:
          PO                                       Urine                                              Total I ____ O
          TF                                       NG                                                 PO _____     Urine
          IV                                       Drains                                             TF _____     NG
                                                   Other                                              IV _____     Drains
                                                                                                                   Other
    Weight:      Admission: _______ lbs.               Current: _______ lbs.
                 Gain: ______ lbs.                     Loss: _______lbs.
    Balanced                 Excess             Deficit 

Calculate the normal fluid maintenance requirements (see Chart below):
        _______________ for 24 hours



                Fluid Maintenance Requirements
Weight (kg )                       Requirements over 24 hours
0-10 kg                            108 ml/kg
10-20 kg                           1,000 ml for first 10 kg + 50 ml for
                                   each kg over 10 and under 20
More than 20 kg                    1,500 ml for first 20 kg + 20 ml for
                                   each kg over 20 kg



IV Lines
Note:       Type =       Saline Lock (SL)                  Broviac: Double lumen (BD) / Single lumen (BS)
                         Peripheral (P)                    Infusaport: Double lumen (ID) / Single lumen (IS)
                         PICC – Peripheral / Central

Type     Gauge     # Lumens       Location       Date      Site Appearance   Dressing Appearance        Solution       Rate   Tubing
                                               Inserted                                                                        Date




NSG 225 Proc Tool - 08                                             22
                                    NUTRITION (Exchanging)                                         Changes from Assessment Day
Height/Weight Measurements:
   Normal range for age:
       Ht. ______cm ______%ile                 Wt. ______kg         ______%ile
      Actual:
          Ht. ______cm ______%ile              Wt. ______kg         ______%ile
      Weight Change _______lbs.           Intentional 
       Unintentional  Explain ____________________
Diet:
    Describe the normal diet for this patient’s age:




      Is this the diet the patient is eating at home? Yes            No 
      Diet order in hospital
      % meals eaten:        B _____       L ______           D ______                              % eaten:
                                                                                                   B ____ L ____ D ____
      Anorexia 
      Method used for eating / drinking ___________________
      Alternative diet:
        Tube feeding:   NG       GT         J Tube 
          Formula _______________(type) _________ml    Water flush ______ml
          Placement checked          Yes         No             Residual _____________ml
        TPN       Rate ______           Lipids  Rate ______
Mouth:
   Buccal cavity:        Moist      Dry         Intact         Thrush 
      Teeth:    # teeth: Norm for age ________                   Actual ________
        Permanent: Full Set         Missing  Decayed               Braces      Orthodontia 
GI:
      Swallowing: Dysphagia          No Problem                     Sucking difficulty 
      Discomfort: Heartburn  Flatulence  Reflux                    No Problem 
      Bowel Sounds:       Present        Absent          Hypo         Hyper
                RUQ                                                    
                LUQ                                                    
                LLQ                                                    
                RLQ                                                    

      Abdomen: Soft            Firm     Distended             Tender      Site ___________
Blood Glucose Monitoring:            None 
   Last 2 Results
       Date        Time                      Result
1                                                                                                  Last 2 Results
                                                                                                     Date Time Result
2                                                                                                  1
                                                                                                   2
NSG 225 Proc Tool - 08                                               23
                                ELIMINATION (Exchanging)                                   Changes from Assessment Day
Urinary:
    Urine characteristics:
         Color ________        Odor ________
         Clarity:   Clear  Cloudy          Concentrated  Sediment           Bloody 
         Bladder trained       Yes      No 
         Continent:           Incontinent 
    Pattern:    Urgency         Frequency        Retention       Dysuria 
    Words used for urine _________________________________
    Assistive Device:
         Foley  Size _____           # Lumen ______    Anchored        Yes     No 
         Suprapubic 
Bowel:
    Last BM (date): _________ Preadmission pattern: ______________
    Stool Characteristics:
         Color ___________        Consistency:       Frequency: _______
                                  Diarrhea          Bowel Prep:
                               Constipation         Yes        No 
                                  Impaction 
                                      Formed 
         Bowel trained         Yes      No 
         Continent          Incontinent 
         Words used for stool ______________________________
         Decompression Device:           NG         GT         JT 
                Suction         Continuous       Low Intermittent Suction 
                Gravity 
                Clamped         Reason: _________________________
                Drainage: Color: ______________         Amount: __________
                                                        (this shift)
Ostomy:      None 
    Stoma          Location __________________         Type: __________
                Color ___________________          Skin Condition _________
    Appliance:      Intact       Needs to be changed 
Isolation:
    Yes        No         Urine      Stool     Organism ____________




NSG 225 Proc Tool - 08                                      24
             PHYSICAL INTEGRITY / PHYSICAL REGULATION (Exchanging)                        Changes from Assessment Day

Temperature ____________ Normal for age Yes                        No 
    Normal range for age ______________
    Method: Oral  Rectal                Axilary      Temporal            Tympanic 
Skin/Tissue:
    Hygiene:       Clean        Unclean           Odor 
    Skin: Intact         Not intact             Site _____________________
          Dry            Diaphoretic 
    Umbilical cord: Drying           Redness          Drainage         Odor 

Skin Changes:                                           Location
             Rash                     
             Petchiae                 
             Ecchymosis               
             Old Scars                
             Abrasion/laceration      

Wounds/Incisions: Location:
    Appearance:
      Unable to assess  Dressing dry/intact                  Yes  No                   Mark skin changes, wounds, incisions on
                                                                                          diagrams.
      Approximated              Dehisced 
      Redness           Warmth          Edema  Tenderness 
      Other 
      Drainage:          Yes        No          Describe __________________
    Size __________cm.
    Type Closure:                     Intact?
      Steri Strips                       
      Staples                            
      Sutures                            
      Retention Sutures                  

    Drains:        JP       Hemovac               Penrose        Other _____________
      Location ___________                Drainage Color ____________________
      Drain site skin condition:
               Unable to assess 
               Redness          Warmth            Edema          Drainage 
      Drain dressing intact: Yes  No 
               Dressing change Yes  No 
    Wound Vac            Yes         No 
      Foam compressed                        Opsite intact     

      Pressure ________ mm. Continuous                       Intermittent    

      Drainage (describe) _____________________________________
Isolation:
    Yes         No        Site ______________               Organism __________



NSG 225 Proc Tool - 08                                               25
                                      REPRODUCTIVE (RELATING)                                        Changes from Assessment Day
Female:
    Tanner Stage: 1                  2        3         4         5 
    Breasts: Symmetrical                Asymmetrical 
    Menses: Menstruation                   Pattern ______________
                 Age of onset __________              LMP __________
    Vagina:      Discharge            Color _______________                            Odor 
    Pregnant: Yes            No           # of Months ______________
    Previous Pregnancy 
    Hormone Therapy:                  Birth Control            Other 
Contraceptive use  Type ____________________
Male:
    Tanner Stage: 1                  2        3         4         5 
    Breasts: Symmetrical                Asymmetrical 
    Penis: Circumcised                Discharge  Color __________                         Odor 
Contraceptive use  Type ____________________


                                                    MOVING                                           Changes from Assessment Day
Fall Risk Assessment
          Recent Fall
          Mobility, Balance Problem
          Confusion/Disorientation
          Medications (Hypnotics, Sedatives, Antidepressants, Analgesics)
          Unstable hemodynamics (BP, etc.)
          Elimination (urgency, frequency, incontinence)
          Sensory deficit (special senses)
    Bed/Chair Alarm           Yes                  No 
ROM:                Right      Arm          Leg                Left    Arm           Leg

    Full                                                                             

    Limited                                                                          

Strength:
    Weak                                                                             

    Strong                                                                           

    Tremors  Site                                   Twitching  Site
ADL’S:              Self    Minimal      Partial      Complete            PT        OT      Speech
                            Assist       Assist        Assist
    Eating                                                                             
    Hygiene                                                                            
    Transfer                                                                           
    Ambulate                                                                           
    Turn                                                                               

    # of Assists ________

NSG 225 Proc Tool - 08                                                         26
                                  MOVING - Continued                            Changes from Assessment Day
Activity:
    Order:          BR     Chair       BRP 
                    Ambulate in room      Hall     Ad lib 
    If unable to implement activity order, why? _______________________
    Ambulation (describe):
          Gait                      Distance
          Posture                   Aids
          Response (pain, SOB, fatigue, etc.) _________________________
Sleep/Rest:
    Nighttime rituals _________________________
    Special belongings used at night ____________________________
    Number of hours normal for age: __________           Actual hrs of sleep
    Difficulty sleeping Yes      No        Feels refreshed     Yes    No 
    Nightmares
    Aids
Safety:
    Side rails                       2      4 
    Bed in low position                 Call light in reach 
    Restraint  Type                       Form implemented Y  N 
    Room clutter minimal       Electrical cords away from ambulation path 
Developmental norms for age
    Describe norms for this patient’s age in boxes below:
    Fine motor:




    Is patient’s fine motor appropriate for age? Yes  No 
        If no, patient is Above  Below 




NSG 225 Proc Tool - 08                                      27
                                MOVING - Continued                    Changes from Assessment Day
    Gross motor:




    Is patient’s gross motor appropriate for age? Yes  No 
        If no, patient is Above  Below 
    Play activities




    Are patient’s play activities appropriate for age? Yes  No 
        If no, patient is Above  Below 
    Peer interactions:




    Are patient’s peer interactions appropriate for age? Yes  No 
        If no, patient is Above       Below 


NSG 225 Proc Tool - 08                                  28
                                PAIN / COMFORT (FEELING)
                    ACUTE                              CHRONIC                                                 Changes from Assessment Day

Location                                               Location
Radiation Yes                  No                    Radiation Yes           No 
     Where                                                  Where
Intensity                                              Intensity
Pain Level (0-5)                                       Pain Level (0-5)
Wong Face Scale (0-5)                                  Wong Face Scale (0-5)
FLACC Total ____                                       FLACC Total ____
Characteristics                                        Characteristics
 Sharp  Cramping                                      Sharp  Cramping 
  Throb            Burning                             Throb       Burning 
  Ache             Crushing                            Ache        Crushing 
Duration                                               Duration
Frequency                                              Frequency
Nonverbals                                             Nonverbals
 Restless            Grimace                          Restless       Grimace 
  Guarding  Crying                                     Guarding  Crying 
  Unable to focus                                       Unable to focus 
  Other                                                  Other
Precipitating factors                                  Precipitating factors


Relief measures                                        Relief measures
 Non-medication                                        Non-medication 


Medication                                            Medication 
  Name                                                   Name
  Route                                                  Route
  Frequency used                                         Frequency used
  Intensity after Rx                                     Intensity after Rx


                                                                                                      Wong Face Scale


       0-5 numeric Pain Intensity Scale (Children
       ages 8-21)




 0            1         2          3         4         5
No          Mild     Moderate    Severe    Very      Worst
Pain        Pain      Pain        Pain     Severe   Possible
                                                                    FLACC Scale
 Categories                                                                           Scoring
                                         0                                               1                                                2
Face               No particular expression or smile               Occasional grimace or frown, withdrawn,           Frequent to constant quivering chin,
                                                                   disinterested                                     clenched jaw
Legs               Normal position or relaxed                      Uneasy, restless, tense                           Kicking or legs drawn up
Activity           Lying quietly, normal position, moves easily    Squirming, shifting back and forth, tense         Arched, rigid or jerking
Cry                No cry (awake or asleep)                        Moans or whimpers; occasional complaint           Crying steadily, screams or sobs
                                                                                                                     frequent complaints
Consolability      Content, relaxed                                 Reassured by occasional touching , hugging       Difficult to console or comfort
                                                                    or being talked to, distractible
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between 0 and 10.

NSG 225 Proc Tool - 08                                                    29
                                                             CHOOSING/KNOWING
Level of Education                                                   Reliable source: Yes  No 
Learning Barriers:
        Physical Condition           Cognitive               Emotions             Language              Culture/Religion 
        Lack of motivation           No desire 
Health Management, Health Seeking Behaviors Prior to Admission:
Primary Prevention / Promotion                            Primary Prevention / Promotion Continued
                                                          Immunizations: List # and names child should have had
                         Yes No Describe
Diet appropriate for age                                _____________________________________________
Special Diet                                                              _____________________________________________
Exercise                                       Frequency                  _____________________________________________
Ideal Body Weight 50th%ile            If not
                                                                            _____________________________________________
Sleep ___ restful hours               If not
Dental Hygiene                                                            Up to date Yes  No 
Alternative health care                                                   Secondary Prevention (appropriate for age)
 methods                                                                                                          Date of Test
Poison Control Measures                                                   None
Seat Belts (driving safety)                                               Dental screening                                     
Helmets(bikes, skates)                                                    Eye exam / Glaucoma:                                 
Car Seat                                                                  Screening for    Lead Levels:                        
Other                                                                                             HTN:                         
Tertiary Prevention                                                                            Diabetes:                         
What do you do at home to manage each of your diseases?                                      Cholesterol:                        
                                                                                                     TB:                         
                                                                                        Hemoccult stool:                         


Personal Risk Factors (May be related to Parents also)                      Family Risk Factors             Yes         No
                          Yes    No     Describe                            Diabetes                                   
Occupational Risk                                                         Hypertension                               
Risky behavior                                                            Heart disease                              
Tobacco/Smoking                       Type                                Stroke                                     
     Packs/day ____ x # of yrs. smoked ______ = _____ pack yrs.             TB                                         
     Last use _____________                                                 Lung disease                               
     Parents Smoke                                                        Kidney disease                             
Alcohol use                           Type                                Cancer                                     
     Frequency ______________ Amount __________ Last Use                    Autoimmune                                 
     Parents use                                                          Mental Illness                             
Street Drug Use                       Type                                Chemical Dependency                        
     Frequency ______________ Amount __________ Last Use
     Parents Use                
Teaching / Learning Need: (May be related to Parents also)
     What information would you like while you are here?
     Priority education need identified by nurse at this time
     Medication teaching needed
     New preventive care needed at home on discharge:
           Primary
           Secondary
           Tertiary
NSG 225 Proc Tool - 08                                             30
                                            RELATING/PERCEIVING/FEELING/VALUING
Psychosocial Information:
    Parent’s Marital status:      Single       Married      Divorced          Widowed          Separated         Recent change 
    Parent’s Occupation
    Ethnic Group
    Religion: Type                                 Practicing: Yes       No       Religious restrictions to care
         What can we do to help you spiritually at this time? Nothing              

    Finances:     Self Pay         Insurance          Medicare            Medicaid         ADC 
    Legal issues:        Foster care  Restraining order  Custody/Guardian  Other (jail, DUI, rape, etc.) 
Living Arrangements – Where / With Whom:
         Home           LTC     Homeless Shelter                       Other 
         Relatives                                 Friends         Caregiver         Children’s Protective Services (CSB) 
    Home Environment: # People                                               Ages
         # Floors                       # Stairs                             Bath, Bed, Kitchen same level 
         Air Conditioning        Heat         Water      Electric         Telephone           Cordless 
    Community Environment:          Violent        Nonviolent 
Support System:
    Roles                                                             # Children
    Support system at home                                            Support system in hospital
    Patient/family strengths to be reinforced
Emotional Status:
    Calm         Anxious        Angry        Withdrawn       Fearful        Irritable      Stressed           Grieving 
    Bonding attachment behaviors ________________________________________
    Concept of death ___________________________________________________
    Fears or concerns about this hospitalization or illness
    Child’s normal reaction to hospitalization for age _______________________________________________________
Response to current situation:
    Erikson:      Stage of development
         Task:                        vs.                                    Resolution: Positive        Negative 
    Maslow: Priority need:
         Physiological 
         Safety          Self-esteem       Love/belonging          Self actualization 
Anticipated care needs:
    Living arrangements:         Change from preadmission        Yes         No 
         Where is patient planning on going after discharge?
         Where is doctor planning to send patient after discharge?
    Assistance needed:                None 
         Shopping            Transportation         Meals          Medications           Finances        ADL’s        Shelter 
         Who will help with care?
    Equipment needed:
    Referrals needed:
NSG 225 Proc Tool - 08                                          31
                                           Directions for Summary and Analysis of Assessment

                                   Oxygenation          Circulation          Development
                                                                                                  Nutrition
                                                                                                                   Growth
                               Elimination

                                                                                                                  Hydration
                               Neuro
                                                                   Current Problem

                                                                                                                    Choosing /
                           Perceiving /                                                                             Knowing
                         Relating/ Valuing

                                                                                                              Communicating
                               Reproductive
                                                        Physical                            Feeling
                                                        Integrity/
                                                                             Moving
                                                        Regulation

1. Identify the reason patient sought health care, the medical / surgical diagnosis, in center circle.
2. Review assessment. In each response box, place assessment data that relates to the response. Data to be noted includes health history, abnormal
   assessment findings, abnormal labs and diagnostic studies, medications, IV’s, treatments (O2, wound care, etc.). Each box contains only data that
   relates to that response but data may relate to more than one response/box (example, dyspnea could be in oxygenation and moving).
3. Analyze the data in the response boxes and identify problem areas (those with the majority and most significant data). Problem areas may be related to
   medical diagnosis on admission, the health history, or a new problem. Prioritize the top 3 problem areas. Place a 1, 2, and 3 in the right lower corner of
   the top 3 response boxes.
4. Write the complete nursing diagnoses that reflect the 3 top problem areas on the analysis of assessment page. The nursing diagnoses may be an
   actual or a risk. An actual diagnosis is stated in three parts – the NANDA statement, the RT which is specific to the pathophysiology for the patient, and
   the AEB which is data directly from the patient’s assessment. The RT is not stated as the medical diagnosis. For example the related to for ineffective
   cardiac output could be necrosis of the myocardium, but not MI. A risk diagnosis is a statement of a problem that is likely to develop unless the nurse
   intervenes. It is stated in 2 parts – the NANDA statement and the RT. The RT may be further explained by its cause and stated as associated with.
   Example, Risk for ineffective gas exchange RT consolidation of lung tissue associated with lung cancer.
5. Include 1 psychosocial nursing diagnosis for child or family.
6   Using your pathophysiology content, write a PC nursing diagnosis on the analysis of assessment page. A PC diagnosis is a medical condition that is a
    complication of the current or co-existing medical problem or surgery and is stated as PC of ______: ______. Example, PC of thrombophlebitis:
    pulmonary embolus; PC of surgery: hemorrhage.
7. Develop the top 1-2 priority nursing diagnoses into the patient’s plan of care. PC or risk diagnosis may be priority number 1.

8. In NSG 221, 223, 224, and 225 identify a wellness diagnosis using approved format of “Readiness for Enhanced…..” (Ex. Fluid balance,
   communication).
NSG 225 Proc Tool - 08                                                          32
                                                                   Summary of Assessment Map

                   Oxygenation                       Circulation                      Development    Nutrition




                                                                                                       Growth




                  Elimination


                                                                                                       Hydration




                       Neuro


                                                                                                     Choosing / Knowing




                                                                                                       Communicating

     Perceiving / Relating/ Valuing




                                      Physical Integrity/Regulation                   Moving        Feeling
            Reproductive




      Health history
      Abnormal diag/lab
      Abnormal ass’t
      Meds, IV’s, treatments


NSG 225 Proc Tool - 08                                                        33
                                                    Analysis of Assessment

After analyzing your summary of the patient’s assessment, write the 3 highest priority nursing diagnoses. These may be an
actual NANDA __RT__AEB__, or a risk, Risk for NANDA__RT__. The nursing diagnosis(es) that will be used for the plan of
care should not be stated here, but on the top of the POC sheet. Write “see plan of care” next to the number on this page.
Include a minimum of 1 psychosocial nursing diagnosis (Not anxiety or coping).

1.)




2.)




3.)




For tertiary prevention, the highest priority PC nursing diagnosis for this patient is: (only one)

1.)




Wellness diagnosis:

1.)




NSG 225 Proc Tool - 08                                           34
Interventions: Assessments trended, diagnostic & labs,
meds, IV’s, treatments, nursing actions, teaching.
                                                              PLAN OF CARE

Nursing Diagnosis (ND):


       OUTCOME(S)                               INTERVENTIONS WITH RATIONALES                              EVALUATION OF
                                                                                                            OUTCOME(S)
Specific to this ND with            # each intervention. State in specific terms. Document rationale
Expected Patient Responses          with RAT: immediately after intervention. Indicate actions          Changes Made/Needed
                                    delegated to PCT with a “D” before the action.
                                    Include patient teaching plan.
                                                                                                           Met       Not Met 
                                                                                                            Partially Met 

                                                                                                       Data supporting decision:




                                                                                                       Changes:




NSG 225 Proc Tool - 08                                                 35
Nursing Diagnosis Continued


       OUTCOME(S)             INTERVENTIONS WITH RATIONALES       EVALUATION OF
                                                                   OUTCOME(S)

                                                                  Met       Not Met 
                                                                   Partially Met 

                                                              Data supporting decision:




                                                              Changes:




NSG 225 Proc Tool - 08                       36
Interventions: Assessments trended, diagnostic & labs,
meds, IV’s, treatments, nursing actions, teaching.
                                                              PLAN OF CARE

Nursing Diagnosis (ND):


       OUTCOME(S)                               INTERVENTIONS WITH RATIONALES                              EVALUATION OF
                                                                                                            OUTCOME(S)
Specific to this ND with            # each intervention. State in specific terms. Document rationale
Expected Patient Responses          with RAT: immediately after intervention. Indicate actions          Changes Made/Needed
                                    delegated to PCT with a “D” before the action.
                                    Include patient teaching plan.
                                                                                                           Met       Not Met 
                                                                                                            Partially Met 

                                                                                                       Data supporting decision:




                                                                                                       Changes:




NSG 225 Proc Tool - 08                                                 37
Nursing Diagnosis Continued


       OUTCOME(S)             INTERVENTIONS WITH RATIONALES       EVALUATION OF
                                                                   OUTCOME(S)

                                                                  Met       Not Met 
                                                                   Partially Met 

                                                              Data supporting decision:




                                                              Changes:




NSG 225 Proc Tool - 08                       38
                                                 Directions for Plan of Care

Outcomes:

   Outcomes reflect the nursing diagnosis and are a positive restatement of the nursing diagnosis.
   Expected patient responses are specific assessment findings indicating achievement of the outcome. They are
    focused and measurable. An example for an actual diagnosis is that the patient will be free of ineffective gas exchange
    (or will have improved gas exchange, or no further decrease in gas exchange). Expected responses would be clear
    breath sounds, respiratory rate 16-20, O2 sat of 96%, etc. An example for risk nursing diagnosis is patient will maintain
    effective gas exchange. Expected responses the same. An example of a PC is PC of surgery: atelectasis. The
    outcome is patient will not develop atelectasis. Expected responses same.
   An additional outcome may be developed to reflect teaching intervention. Example: patient will demonstrate use of an
    inhaler. An expected response would be a correct return demonstration.

Interventions:

   Interventions are orders and actions being done specifically for the nursing diagnosis, to resolve the diagnosis and
    meet the outcome. Interventions include:
         1.     assessment that is trended because of the nursing diagnosis – what will be assessed, for example, to
                indicate worsening ineffective gas exchange.
         2.     doctor’s orders
                 Labs and diagnostics ordered that specifically indicate or trend improvement / worsening of the nursing
                      diagnosis – CBC for the patient who is bleeding.
                 Medications and IV’s
                 Treatments – activity, diet, wound care, etc.
                 Interdisciplinary treatments – PT, RT, etc.
                 REMEMBER: Dr.’s orders have a corresponding nursing intervention. First write order, then nursing
                      interventions. For example: Respiratory treatment with Albuterol q4h. Assess breath sounds, sputum,
                      heart rate after treatment.
         3.     nursing interventions – deep breathe and cough, turn q2h, HOB elevated at 30 degrees, etc.
         4.     teaching specific to the nursing diagnosis.
   Interventions are stated in specific terms (what, where, how often), individualized for the specific patient - offer 200 ml’s
    of fluids q4h or Demerol 25 mg. q4h for abdominal pain. Avoid statements such as encourage fluids or give pain meds.
   Teaching interventions are specific to one topic. For example, if the intervention is to teach care of the incision at
    home, the specifics of shower only, leave steri-strips on until they fall off, etc must be stated. Teaching interventions
    should include teaching related to medications. For example, if the patient is on Coumadin, the intervention would be
    to teach bleeding precautions, specific meds and foods to avoid.
   The interventions are ones the nurse will complete. The phrase “the nurse will” should be placed at the start of the
    intervention column as a reminder, but should appear only once in that column.
   If an intervention is to be delegated, it should be marked before it with a “D”. But if an intervention is delegated, the
    nurse’s follow-up action must be identified. For example, if vital signs q4h are delegated, the nurse must assess the
    results.
   Each intervention is to be numbered.
   Rationales must follow each intervention and are indicated by RAT: Rationales indicate how the specific intervention
    will be used to treat the nursing diagnosis and meet the outcome. For example, if the nursing diagnosis is ineffective
    gas exchange, the intervention is to turn and reposition q 2 h, the RAT would be to allow full ventilation of lungs and
    mobilize secretions (not allow to breathe better).

Evaluation:

   Evaluation is documented at the end of the clinical week.
   Met/not met/partially met refers to the total outcome, not each individual expected patient response (ex., improved gas
    exchange is met or not).
   Decision as to met/not met/partially met is based on whether or not the expected patient responses were
    accomplished.
   Data supporting that decision are actual patient assessment findings as compared to the expected patient responses.
    If expected response is respirations 12-20, data supporting outcome met would be resp. 16, or if not met, resp 32.
   Changes are summary statements as to what was changed since day 1 and/or what needs to be changed in the
    nursing diagnosis, outcome, interventions. Changes are identified at the end of the week.


NSG 225 Proc Tool - 08                                         39

								
To top