NURSING PROCESS ASSIGNMENT (NPA) - Monroe Community ...

NURSING PROCESS ASSIGNMENT (NPA)PURPOSES:To apply the nursing process to an adult patient care situation.To establish priorities and demonstrate clinical decision making.PREPARATION:Review Lewis, pp. 9-16. Prepare Part 1 prior to experience.REQUIREMENTS:Submits a complete assignment according to the criteria, in ink, two weeks following theexperience.Submission of the NPA must include a copy of a professional article based on research andpertinent to the Nursing Diagnoses chosen. Patient education tools are not acceptable. Thefollowing is a listing of suggested search engines or websites that may be helpful:www.ncbi.nLm.nih.gov/PubMed – a generic site with lots of informationwww.cdc.govhttp://child.nih.govhttp://healthweb.org/brose.cfm?subjectid=60www.martindalecenter.com/nursing.htmlhttp://gateway.nLm.nih.gov/gw/Cmd – single interface for informationResearch/Ev.dence Based Article: (from back of assignment)Research/Evidence Based Article:Identify a current nursing based article (less than 6 years old) that presents information that can beutilized at the bedside and implemented in your care plan. This article should present eitherresearch or evidence based information that directly relates to your patient’s identified nursingdiagnosis, outcomes, or therapeutic nursing interventions.Write a 2-4 paragraph annotated bibliography that includes the following:a brief description of the articlerelevance of the information to your patientany bias or weaknesses in the articlehow you would incorporate this information in your patient’s plan of care.Information concerning how to write an annotated bibliography or APA format can be found athttp://www.monroecc.edu/depts/library/Search for annotated Bibliography or APA format.CRITERIA:Criteria are listed on the checklist at the front of the assignment pages.

NUR 214Nursing Process Assignment Criteria SheetStudent Name:Part 1: Preparation for Clinical1. Formulates possible reason(s) for eachmedication..2. Identify individualized focused assessment withrationale.Part 2: Patient Assessment and Nursing Diagnosis1. Specifies subjective and objective data to assesseach basic need of the patient, including acomplete system assessment where indicated.2. Specifies patient’s understanding of health status,discharge planning and health promotionbehaviors.3. Formulates five individualized nursing diagnosesbased on the data in the assessment.4. Categorizes each of the five nursing diagnoses ashigh, medium, or low priority.Part 3: Nursing Care Plan and Evaluation1. Select two of the individualized NANDA nursingdiagnoses of high priority.2. Identifies defining characteristics and sufficientsubstantiating data for each of the two nursingdiagnoses.3. Establishes at least two individualized patientoutcomes for each nursing diagnosis.4. Establishes at least four individualized highpriority therapeutic nursing interventions to assistthe patient in achieving the identified outcomes.5. Specifies to what degree each outcome wasachieved. (Yes, partially or no)6. Specifies patient data which shows the level ofoutcome achievement.7. Identifies adaptations made to nursing care.8. Determines modifications to patient care asindicated by evaluation of outcomes.Part 4: Research/Evidence Based Article1. Attach 1 copy of appropriate article2. Annotated Bibliography with citation in APAformatProfessional Behavior:1. Submitted on time.2. Written in ink.3. Written legibly.Date of Clinical:MS DNMS Comments

NUR 214 Nursing Process AssignmentPart 1: Preparation For ClinicalStudent Name ________________________ Meets Standard Does Not Meet StandardPatient Initials ______ Date of Clinical ____________________MedicationReason Patient is takingPre/Post Nursing AdministrationConsiderationsIdentify components of a focused assessment for this patient with rationale.Focused Assessment (in priority order)Rationale

NUR 214 Nursing Process AssignmentPart 2: Patient AssessmentGeneral InformationPatient Initials Age: Gender: ___________History of present illness:Allergies:Past medical/surgical history:Current vital signs: T P BP R SpO 2 Pain Level _____Baseline vital signs (ranges): T P BP R SpO 2 ____________ Pain level ___________Data Collection for each Basic NeedPast Medical HistorySubjective Data(Subjective information obtainedfrom patient)Objective Data(Assessment findings based onsubjective information)Relevant LaboratoryValues & Diagnostic TestsRelevantMedicationsOXYGEN (Cardiovascular Assessment)Subjective DataObjective DataOXYGEN (Respiratory Assessment)Subjective DataObjective Data

REST/SLEEP/COMFORT (include Pain and Integument Assessment)Subjective DataObjective DataACTIVITY (includes Musculoskeletal Assessment)Subjective DataObjective DataFLUIDS AND URINE ELIMINATION (includes IV Site Assessment)Subjective DataObjective Data

NUTRITION (includes Oral Assessment)Subjective DataObjective DataBOWEL ELIMINATION (includes Abdominal Assessment)Subjective DataObjective DataSAFETY AND SECURITY: Neurological AssessmentSubjective DataObjective Data

SAFETY/SECURITY (environmental assessment)Subjective DataObjective DataHIGHER LEVEL NEEDSLOVE/BELONGING (includes assessment of patient’s interaction with support person(s))Subjective DataObjective DataRECOGNITION/ESTEEM (includes educational level, occupation, etc.)Subjective DataObjective Data

UNDERSTANDING OF HEALTH STATUS (includes learning strength, capabilities, barriers and educational needs)Subjective DataObjective DataDISCHARGE PLANNING NEEDS (includes assessment of ability to access available community resources)Subjective DataObjective DataHEALTH PROMOTION BEHAVIORSExercise at homeDiet at homeMedications at home (include OTC)Tobacco (packs/no. years)CaffeineAlcohol (type/amount/frequency)Other substancesAlternative/Complementary Therapies

OTHER (includes Assessment of Developmental, Socioeconomic, Emotional, Cultural, Religious and Spiritual influences on patient’s health.)SubjectiveObjective

NUR 214 Nursing Process Assignment1Nursing Diagnoses (NANDA) and Related Factor(s)Priority RankingHigh Med. Low2345

NUR 214 Nursing Process AssignmentPart 3: Nursing Care PlanNursing Diagnosis of High Priority #1DefiningCharacteristicsSubstantiating DataPatient Outcomes(At least 2 per diagnosis)High Priority Therapeutic Nursing Interventions(At least 4 per diagnosis)1111Revised 6/07

NUR 214 Nursing Process Assignment:Part 3: Evaluation1.Nursing Diagnosis #1:Patient Outcomes_____ Met_____ Partially MetPatient Data Showing OutcomeAchievementAdaptations Made to NursingCareEmotionalModification as indicated by Evaluation ofOutcomesShould Nursing Care Plan be:____ maintained?____ changed?____ discontinued?_____ UnmetRationale2._____ Met_____ Partially Met_____ UnmetDescribe how the patient’s participation in care facilitated/ impairedthe achievement of these outcomes:CulturalReligiousSpecify changes if anyNursing DiagnosisOutcomesSpiritualTherapeutic Nursing InterventionsValues/Customs/Habits1212Revised 6/07

Nursing Diagnosis of High Priority #2DefiningCharacteristicsSubstantiating DataPatient Outcomes(At least 2 per diagnosis)High Priority Therapeutic Nursing Interventions(At least 4 per diagnosis)1313Revised 6/07

1.Nursing Diagnosis #2:Patient Outcomes_____ Met_____ Partially MetPatient Data Showing OutcomeAchievementAdaptations Made to NursingCareEmotionalModification as indicated by Evaluation ofOutcomesShould Nursing Care Plan be:____ maintained?____ changed?____ discontinued?_____ UnmetRationale2._____ Met_____ Partially Met_____ UnmetDescribe how the patient’s participation in care facilitated/ impairedthe achievement of these outcomes:CulturalReligiousSpiritualSpecify changes if anyNursing DiagnosisOutcomesTherapeutic Nursing InterventionsValues/Customs/HabitsRevised 6/0714 14