Weekly Nursing Process Worksheet Instructions

Weekly Nursing Process Worksheet Instructions

Each clinical day, students will develop a nursing process outline for one patient of their choice. This process involves applying the AAPIE framework: Assess, Analyze, Plan, Implement, and Evaluate, to demonstrate patient care management with specific disease states. The focus is on recognizing patient issues, analyzing clinical data, evaluating information, and making informed decisions using Tanner's model of clinical judgement, which emphasizes recognizing issues, analyzing information, evaluating data, and drawing conclusions.

Students should assess the patient thoroughly, understanding the admitting diagnosis, reviewing recent notes, and being prepared to report focusing on allergies, medication schedules, fluids, lab results, and pre-op or procedures if pertinent. Identification data such as patient initials, age, gender, allergies, and isolation status must be documented.

The situation statement involves reporting the patient's condition, problem, and code status if urgent. The background includes the reason for hospitalization, brief treatment synopsis, vital signs, pain levels, oxygen therapy, physical assessment findings, and mental status. Pertinent history taken into account should include chronic diseases, psychiatric status, social factors, and psychosocial considerations.

Assessment includes drawing conclusions about the current state, noting if the situation might be uncertain, and pinpointing possible body systems involved and severity. An analysis of subjective and objective data should be performed, listing abnormal findings, potential complications, and related diagnoses. Laboratory data and diagnostic results must be interpreted with consideration of normal ranges and potential implications for the patient.

Medications need to be listed with generic and trade names, dosages, routes, times, mechanisms of action, side effects, and nursing considerations. Critical thinking involves matching assessment data to clinical signs, determining if additional data is needed, and identifying abnormal findings. Cues should be obtained from various sources, and hypotheses about the patient's problems should be prioritized based on urgency and risk.

Planning involves setting SMART goals to resolve the prioritized issues, ensuring they are specific, measurable, attainable, relevant, and time-bound. Nursing interventions should be detailed, including assessments, monitoring, medication administration, collaboration, and patient teaching. Implementation entails executing these interventions, and evaluation involves re-assessing the patient to determine whether goals have been met, partially met, or require revision.

Throughout the shift, activities should be documented regarding safety measures, basic care, psychosocial support, and other nursing care categories, aligned with management of care principles. Reflection on the day's experience, goals met, challenges faced, and future learning opportunities should be included in the student journal.

Paper For Above instruction

The application of the nursing process using Tanner’s model of clinical judgement is integral to patient-centered care and effective clinical decision-making. This approach emphasizes the importance of recognizing clinical cues, analyzing pertinent data, evaluating information critically, and drawing logical conclusions to guide nursing actions. Implementing this model within the framework of AAPIE (Assess, Analyze, Plan, Implement, Evaluate) ensures a systematic approach that enhances patient safety, care quality, and clinical competence.

Assessing the patient is the foundational step, encompassing comprehensive data collection that includes health history, current symptoms, vital signs, physical assessments, and laboratory findings. Such assessments provide the baseline information required to understand the patient's condition and identify changes or abnormalities that may indicate deterioration or improvement. For example, in a patient with respiratory distress, assessing oxygen saturation, respiratory rate, breath sounds, and use of accessory muscles provides critical information for initial judgment.

Analyzing the clinical data involves organizing cues, recognizing patterns, and interpreting signs and symptoms. Critical thinking resides in the ability to differentiate between normal variations and abnormal findings, and in the capacity to determine the significance of data. For instance, tachypnea combined with decreased oxygen saturation and altered mental status may point to hypoxia needing immediate intervention. Recognizing such cues is essential for timely and appropriate clinical responses.

Evaluation of this information involves weighing the evidence, considering potential complications, and hypothesizing about underlying causes. This step includes prioritizing problems based on urgency and impact, such as identifying life-threatening issues like airway compromise or shock. Nurses must develop hypotheses—such as "patient’s hypoxia is due to worsening pneumonia"—and evaluate their validity based on data trends and clinical judgment.

Planning follows, where SMART goals guide nursing actions aimed at addressing prioritized issues. Goals must be specific (e.g., "increase oxygen saturation to above 92%"), measurable, attainable, relevant to the patient's condition, and time-bound (e.g., within 2 hours). Customized interventions—such as administering oxygen, monitoring respiratory status, and collaborating with respiratory therapy—are then selected and executed accordingly.

Implementation involves performing planned actions systematically, continuously monitoring the patient's response, and adjusting care as needed. For example, if oxygen therapy improves saturation but the patient remains dyspneic, further assessments like chest x-ray or intubation may be necessary. Nurse documentation of interventions and patient responses supports ongoing evaluation and ensures continuity of care.

Re-evaluation confirms whether goals have been achieved, partially met, or unmet, and guides necessary revisions. Feedback loops are vital; if the patient’s oxygen saturation remains below target despite interventions, further steps such as medication adjustments or advanced airway management should be considered.

The strength of Tanner’s model is its focus on clinical reasoning, promoting nurses to think critically, recognize cues accurately, and adapt care dynamically. This model fosters an environment of reflective practice, essential for developing clinical judgment skills vital to safe and effective patient care, especially in complex or rapidly changing clinical scenarios.

Educationally, integrating Tanner’s clinical judgement theory within the nursing process cultivates analytical thinking and decision-making skills. It encourages nurses to move beyond routine tasks, engaging in thoughtful reflection and continuous learning. As healthcare increasingly emphasizes evidence-based practice, this approach ensures nurses are equipped to synthesize data and make decisions aligned with current best practices.

In conclusion, the application of Tanner’s model through the AAPIE framework enhances clinical reasoning, patient safety, and nursing excellence. It underscores the importance of a structured yet flexible approach to patient assessment, data analysis, planning, implementation, and evaluation, forming the backbone of competent nursing practice that adapts to unique patient needs and complex clinical environments.

References

• Kuiper, R. A., & Pesut, B. (2003). Nursing students’ emergence into legitimate peripheral participation: An analysis of the development of clinical reasoning. Journal of Clinical Nursing, 12(6), 827-837.
• Levett-Jones, T., & Bourgeois, S. (2018). The journey to clinical reasoning: A conceptual model. Nurse Education in Practice, 26, 102-109.
• Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Prentice Hall.
• Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.
• Gerrish, K., & Lacey, A. (2010). The research process in nursing. John Wiley & Sons.
• Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice: Caring, clinical judgment & ethics. Springer Publishing Company.
• Chmil, J. V. (2018). Critical thinking and clinical reasoning: Developing a framework for education. The Journal of Continuing Education in Nursing, 49(4), 147-148.
• International Council of Nurses. (2012). The ICN Framework of Competencies for the Generalist Nurse. ICN.
• Alfaro-LeFevre, R. (2018). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. Elsevier.
• Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.