DAILY NURSING PROCESS PLAN
NUR 248
1.
2.
3.
Health Promotion
Nutrition
Elimination
NANDA DOMAINS
4. Activity and Rest
7. Role Relationships
5. Perception/Cognition
8. Sexuality
6. Self Perception
9. Coping/Stress Tolerance
13. Growth/Development
10. Life Principles
11. Safety/ Protection
12. Comfort
Date of Care ________ Pt. Initials_____ Age ____ Room #_____EDC_____ Date/Time of Delivery______Gestation________
Pregnancy History: G:_____ P:_____(T:______ P:_____A: ____ L:_____) Type of Birth _____________Reason____________
Wt._______ Ht. _______ Diet _____________ Appetite ____________ Formula/Breast/Frequency____________________
Admitting Diagnosis: ____________________________________________________________________________________
Surgical Procedure (C/S, Episiotomy, Laceration, Anesthesia,)___________________________________________________
PMH/PSH/Social/Family (include birth health history, maternal (pregnancy) health history, childhood medical
history,_________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Allergy to drugs, food, or environment _______________________________________________________________________
Immunization Profile _________________________________________________________________Activity __________
Vital signs: T:_______ Pulse: _______ Apical: _______ RR: _______ B/P: _______ SaO 2 _______ Pain Scale:_________
IV __________________________________________________________________ ( Solution, Site, Gauge, Date, Time)
Intake _________ Output _________ Foley Catheter ____________ Drains _______________________________________
SUBJECTIVE/OBJECTIVE ASSESSMENT: Circle and describe Client’s Stressors
Include positive and significant negative findings. (GIVE DETAILED DATA)
Domain #5, 11: Neurological
B
S:
O:
Domain # 5, 6: Mood/Affect/Emotions
U
S:
O
Domain # 4: Thorax and Lungs
B
S:
O
Domain # 4:Cardiovascular
B
S:
O:
Domain # 4: Peripheral Vascular
L
S:
O:
Domain # 2,3: Gastrointestinal
E
S:
O:
Domain # 3,8: Genitourinary
H
S:
O:
Domain # 4, 11: Musculo-Skeletal
E
S:
O:
Domain # 2, 3, 11, 13: Skin, Hair, Nails
S:
O:
BUBBLE HE
Complete Drug
Order
Safe Dose?
Pregnancy
Category
DAILY NURSING PROCESS PLAN
Classification
Major Therapeutic Effect/
Generic/Trade
Major Adverse Effect
Add additional pages as necessary.
Labs
Client
Expected Values
Values
RBC
Hgb
Hct
Platelets
WBC
Type & Rh
Labs
Client Values
Nursing Responsibilities
Expected Values
GBS Status
Rubella Titer
Hep B sAg
U/A
HIV
Drug Level
RPR
Other
Add additional pages as necessary with interpretation of abnormal values.
Diagnostic Tests; Procedures; Treatments; Dressings:
Client/Parent Teaching Topics: : (include health education/prevention based on developmental age and culture)
PRE/POST-CONFERENCE DIAGNOSES/COLLABORATIVE PROBLEMS
Tentative Nursing
Interventions
Diagnosis
Evaluations
Actual Nursing Diagnosis
Add additional pages as necessary
Nursing Note: Consider Subjective and Objective Data that records Client’s response to interventions for the Actual
Diagnosis/Collaborative Problems
Newborn
Date of Care _________ Pt. Initials ______ Age _____ Room # _____Date/Time of Delivery _____Apgar _____
Birthweight: _________gms. _______lbs._______ oz ________ Length: _______cms _______inches_________
Temp:(should be 97.5ax)________ AP: ___________ RR:_____Skin color: _______________________________
Voiding Pattern: _______________________Stooling Pattern:__________________________________________
Umbilical Site: _______________________Circumcision Site: (if applicable)______________________________
Voided after Circ _______________
BLOOD TYPE _________ COOMBS ___________
Accucheck: __________mg/dL Frequency of Monitoring: _______________
AC#1 __________ AC#2__________ AC#3 __________
Feeding: Breastfeeding/Formula (circle one of both)
Breastfeeding:________________________ Amount of Time on each breast per feeding
___________________________
Formula: ____________________________ Amount taken and tolerated
________________________________________
Frequency of feeding: ________________________ Time of last feeding _____________________
Sleeping:
Numbers of hours during day_________________________________
Numbers of hours during night________________________________
Complete Drug Order
Safe
Dose?
Classification
Generic/Trade
Major Therapeutic
Effect/
Major Adverse
Effect
Nursing Responsibilities
Add additional page as necessary
Labs
Client
Expected
Interpretation of Abnormal Values
Values
Values
Glucose
Type & Rh
Total/ Direct
Bilirubin
PRE/POST CONFERENCE DIAGNOSES/COLLABORATIVE PROBLEMS
Evaluations
Tentative Nursing Diagnoses
Interventions
Actual Nursing Diagnoses