State College of Florida					Associate Degree Program					Nursing Process Worksheet
 
Pt. Initials:__________ Admit Date:__________ Sex m/f:__________ Rm#:__________ Age:_____ Student Name:________________________ Date of Care:__________
Reason for Admission:__________________________________________________________________________________________________________________________ Surgery:__________________________________________________________________________ Significant Medical hx:________________________________________
Current Orders from Chart/Kardex:_____________________________________________________ Code Status:______________________________________________
Oxygen:__________ Foley Catheter:__________ Activity:____________________ Diet:__________ TedHose/SCD’s:__________ Accuchecks:______________________
Dressing Change/Treatments:____________________________________________________________________________________________________________________
IV/Adaptor Site:_____________________ Date Inserted:__________ Site Appearance:____________________________________________________________________
IV Fluids/Additive:_____________________ Rate:____________________ Tubing Change Due:____________________________________________________________
Temperature:_______________ Pulse:_______________ Respirations:______________ Blood Pressure:_______________ O2 SAT:_______________________________
 
Nursing Care Plan
Assessment 
	Nursing Diagnosis 
	Short Term Outcome
	Interventions
	Evaluation