Kent State University
East Liverpool Campus
NRST 20206
NCP WORKSHEET
KSUEL NURSING 20206
Student _________________________________
Date of Care__________________
Occupation ________________ Level of Education ________
Family status ______________________________________
Home environment __________________________________
Socio/Cultural/Religious Orientation ____________________
Patient Initials___________________ Age ______ Rm#_________
Admission Date _____________ Allergies ___________________
Medical-Surgical Dx: _____________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Medical-Surgical Hx: ____________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Referrals _____________________________________________
Activity ______________________________________________
Diet _________________________________________________
Ordered Treatments
Date
Lab & Diagnostics
_________
References Used:
Medications: dosage, time, classification, reason for use
(Include IVs: type, amount, rate, reason)
Normal
Pt. Value
Significance
Definition of Condition:
STUDENT EVALUATION
Evaluation of Care:
Self Evaluation:
INSTRUCTOR EVALUATION
Skills Performed:
Assessment Data
AIR
Day 1 T ______ P ______ R ______ BP _______
PULMONARY ASSESSMENT
Breath Sounds:
FOOD & WATER
Ht. _____________ Wt. ___________
IBW ___________
ELIMINATION
Bowel Sounds:
Condition of A bd:
Last BM:
% Diet Taken ___________________
Characteristic of Urine:
Describe:
Skinurgor:
Mucous Membranes:
CARDIOVASCULAR ASSESSMENT
Heart Sounds:
JVD:
Capillary Refill:
Bilateral Peripheral Pulses:
Edema:
Intake
__________
__________
ACTIVITY/REST
LOC:
Orientation:
Output (trends)
_________
__________
HAZARDS
Fall risks:
Restraints:
Sleep hrs./night:
EKG/Monitor Pattern:
Degree of extremity mobility:
Assistive Devices:
Tolerance of activity level:
SOLITUDE/SOCIAL
INTERACTION
NORMALCY
DEVELOPMENTAL SCR
Physical Appearance:
HEALTH DEVIATION SCR
Developmental Stage:
Immediate lifestyle adjustment:
Effects of condition on
Developmental issues:
Discharge Plans:
Losses:
Home Situation:
Visitors:
Skin Integrity:
Family Support:
Ability to read/follow
Directions:
Activities:
Self/Dependent Care Demands:
Identify Self-Care Assets and Deficits in the SCR
(Highlight Defining Characteristics above)
NURSING DIAGNOSIS:
A=Assets
D=Deficits
(Highlight Defining Characteristics above)
NURSING DIAGNOSIS:
Outcomes:
Outcomes:
Interventions:
Interventions:
Updated: 9/08