CLINICAL APPLICATION OF THE NURSING PROCESS TOOL
Name _________________________
Course _________________________
Instructor _________________________
Client’s initials:__________ Actual Developmental Stage: _________________________
Gender: _____ Age: _____ Perceived Developmental Stage: _______________________
Reason for admission (if applicable) _____________________________________________
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Analysis (nsg.dx) |
Expected Outcomes (client goals) |
Implementation (nursing interventions) |
Rationales (Why? w/ references) |
Evaluation (of goals) |
Scoring Code KeyStudent Name: _____________________
S – Satisfactory
NI – Needs Improvement
U – Unsatisfactory
Please submit this scoring criterion with the Care Plan.
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Area to be scored |
Scoring code |
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1. Analysis |
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0. Determined basic needs of the client which are threatened |
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0. Nursing Diagnosis are in priority order based on Maslow’s Hierarchy of Needs, and ABC’s (airway, breathing, circulation) |
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All parts of the nursing diagnoses present and appropriate (Diagnosis statement, Related to (R/T) factors, patient specific – as evidenced by (AEB) subjective and objective (S / O) data) |
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1. Plan |
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1. Goals are appropriate (time specific, measurable, focused, realistic) and related to the Nursing Diagnosis |
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1. Measures to accomplish goal are appropriate |
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1. Rationale |
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2. Uses scientific principles |
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2. Reference sources are noted |
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1. Implementation |
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3. Nursing actions carried out are specific and appropriate for goal attainment |
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1. Evaluation |
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4. Describes clients responses to nursing interventions |
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1. Determines the extent to which goals have been met (States goal attained, not attained or partially attained) |
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