SUFFOLK COUNTY COMMUNITY COLLEGE

DEPARTMENT OF NURSING
DAILY NURSING PROCESS PLAN
NR 20, 33, 36, 40
Student Name:
Date of Care _______Patient Initials _______ Room # _______ Chronological Age _________Code Status_________________
Weight _______ Height _______ Diet __________________Isolation__________________Glasses/Lenses_________________
Hearing Aid______Oriented_________Disoriented________Admitting Diagnosis______________________________________
________________________________________________________________________________________________________
Surgical Procedure_________________________________________________________________________________________
PMH/PSH________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
Social History/Family History________________________________________________________________________________
________________________________________________________________________________________________________
Allergy to drugs, food, or environment ______________________________________Activity____________________________
Vital signs: T______________(route) Pulse: A_______ R _______ RR _______ B/P ______________________ (L, R)
SaO2 _______________ Pain Scale:_________
IV ___________________________________________________________________( Solution, Rate, Site, Gauge, Date, Time)
Intake __________ Output __________ Tubes/ Drains/Appliances _______________________________________
Assessment Data: Place your initials in the box if the descriptors match your client, otherwise (*) and write a nurses note.
SAFETY: Call bell within reach. Bed in low position.
INTEGUMENTARY: Skin color pink. Skin warm,
Environment clutter free. Fall precautions:___YES ___NO
dry and intact. Mucous membranes pink and moist.
Restraints:___YES___NO Suicide Risk___YES___NO
No skin breakdown.
HYGIENE: ___Complete ___Partial ___Self
WOUND/INCISION: No redness or increased
ORAL CARE: ___Complete ___Self
temperature in surrounding tissues. No drainage.
Wound edges well approximated. Sutures/staples/steri
strips intact.
PSYCHOSOCIAL: Stress:__________________________
MUSCULOSKELETAL: No joint swelling or
Ways of Handling Sress:_____________________________
tenderness. Full ROJM. No muscle weakness.
Emotional Status:___________________________________
Surrounding tissue without inflammation. Steady
Problems Related to Illness/Condition__________________
balance and gait.
NEUROLOGICAL: A & O X 3. PERRLA. Appropriate
SKIN RISK ASSESSMENT: 2 points for each
behaviors. Verbalization clear and understandable. No
positive answer:___poor physical condition,
dysphasia. Active ROJM all extremities. No numbness or
___inactive, ___lethargic, ___poor nutrition,
tingling.
___incontinent, __poor mobility (over 6 = risk)
RESPIRATORY: Respirations regular and unlabored. No
FALL RISK ASSESSMENT: 1 point for each
SOB. No cough. Nailbeds and mucous membranes pink.
positive answer: ___confused, ___seizure disorder,
Breath sounds clear bilateral. No dyspnea on exertion. No
___weak, ___sedated, ___poor judgment, ___poor
nightsweats. O2 therapy: specify_______________________
sight, ___combative, ___unsteady, ___lang.barrier,
CDB/IS_______ Suction_________
___incontinent, ___poor hearing (over 5 = risk)
CARDIOVASCULAR: No chest pain. Pulse regular. No
PAIN ASSESSMENT: Pain Intensity (1-10)______
edema of extremities. Vital Signs Stable.. Extremities warm.
Pain tolerable:___yes, ___no
Brisk capillary refill.
___alert, ___sedated FLACC Score____
GI: Abdomen soft, non-tender. Audible bowel sounds.
INTRAVENOUS LINES: IV site is clear, without
Passing flatus. Stools within own normal pattern and
redness, swelling or pain. PIV___Date Inserted,
consistency.
___Tubing Change. Central Line___Date Inserted,
Tubes___________________Ostomy__________________
___Tubing Change, ___Dsg Change.
GU: Empties bladder independently and without difficulty.
ACTIVITY: BR, OOB, Dangle, BRP, Ambulate
Urine clear and yellow to amber. Catheter____________
Independent____Assist______________________
Ostomy_______________________________________
Sleep Pattern______________________________
NUTRITION: Diet:_______________________
CLIENT ED/DISCHARGE PLANNING:
Appetite:__Good>75% of meal__Fair50-75%___Poor <50%
___Needs Identified
___Self___Assist Diet Supplement___________________
___Client Education Started
DAILY NURSING PROCESS PLAN

Complete Drug
Order

Safe Dose?

Classification
Generic/Trade

Major Therapeutic Effect/

Major Adverse Effect

Nursing Responsibilities

Add additional pages as necessary.

Labs

Labs

WBC

Expected
Values
4.7-6.1 M
4.2-5.4 F
14-18 M
12-16 F
42-52 M
37-47 F
150,000400,000
5,000-10,000

PH

4.6-8

Sodium
Potassium

135-145
3.5-5

Color
Sp.
Gravity
Protein
Glucose

Amber
1.010-1.025

RBC
Hgb
Hct
Platelets

Client
Values

Client
Values

Labs

BUN

Expected
Values
10-20

Creatinine

0.6-1.2

ABG

Client
Values

Expected
Values

CMP

Cardiac
Enzymes
Troponin I

U/A

Chloride
95-105
None
Glucose
70-110
None
(FBS)
CO2 35-45
Ketones
None
Calcium
8.5-10.5
Blood
0-2 RBCs
Magnesium
4.5-5.5 mEq
Add additional pages as necessary with interpretation of abnormal values.
Diagnostic Tests; Procedures; Treatments; Dressings:

Drug
Levels
PT/PTT
INR
Other

Client/Family Teaching: (include health education/ prevention based on cognition and culture)

DIAGNOSES/COLLABORATIVE PROBLEMS
Nursing Diagnoses
Interventions

Evaluations

Nursing Note: Consider the Subjective and Objective Data that records the Clients response to the interventions for the
Actual Diagnoses/Collaborative Problems (Add additional pages as necessary)