Name:__________________________ Faculty Name:__________________________ Date:_____________ N121L-A: Nursing Process Worksheet Instructions: Each clinical day, the student will develop a nursing process outline for one patient of their choice. These will be discussed in clinical and in post-conferences with the faculty. Use the AAPIE Nursing Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the Nursing Process Worksheet. Upload to CANVAS after the conference. DIRECTIONS What needs to be done: Receive Handoff Report Complete Head-to-Toe Assessment Review patient chart: o History and Physical o Progress Notes o Laboratory and Diagnostic Tests o Vital Signs o Medications Completed If not, why? IDENTIFICATION DATA Patient Initials: Age: Gender: Allergies: Isolation: Code Status: o Full Code o DNR o Modified: CHIEF COMPLAINT ADMITTING DIAGNOSIS 1 Pathophysiology Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the patient. Use academic, evidence-based references to support each criteria. Pathophysiology of Admitting Diagnosis Signs