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Student Name:_____________________________________ Facility: ________________ Date: _____________

Advancing Clinical Practice: Nursing Process Worksheet Page 1 of 2


Client Abilities: Limitations: Needs: Investigate Comorbidity: Actual and Potential Risk Factors:
Profile: Determine strengths Determine weaknesses how current illness 1) List all disease processes. 1) Assess and describe potential and actual
and describe how it and describe how it affects client’s life risk factors.
impacts recovery. impacts recovery. (based on Maslow’s 2) Analyze abilities, limitations, and
hierarchy of needs) needs to determine what makes the 2) What measures will you take to prevent
client vulnerable for complications. and minimize each risk?
Admission
Date:
______

M / F

Age:______
_

FC /
DNR

Allergy:
Y / N

Ht:_______
_

Wt:_______
_

Diet:
______

Activity:
____

Anticipate
d
Discharge
Date
______
Admission
Date:
______

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:

Revised 5/1/2010—NTCC College of


Nursing