Medical Surgical Nursing I

The Nursing Process

Student______________________Date of care________________
Pt. Initials _____Room No._____________Age_________Gender________________

1. Assessment: Prior to your clinical day review the patient record. Cluster significant
assessment findings into the Gordon’s Functional Patterns table. Your head to toe
assessment will be documented in the patient’s electronic record. List possible nursing
diagnosis related to the clusters. For the possible nursing diagnosis, note defining
characteristics that are missing after your chart review in the missing data column. It is
not necessary to fill in every cell of the table. You should have data in all three columns.
You may use additional pages as needed.

Possible Nsg. Or
Health Pattern Data Cluster Collaborative Missing Data
Problems
Health perception/
maintenance

Nutrition/metabolic

Elimination

Activity/Exercise

Sleep/rest

Cognitive/perceptual

Coping/stress
tolerance

Role/relationship

Sexual/reproductive

Value/belief
 Medical Surgical Nursing I
The Nursing Process
Gordon, Marjory. (2002) Manual of Nursing Diagnosis. 10th ED., pp. 3-1
 Medical Surgical Nursing I
The Nursing Process

2. Nursing Diagnosis/Planning/Intervention: Using Maslow’ s Hierarchy, list the top four nursing diagnosis from Gordon’s in order of priority on the concept
map. All Nursing diagnoses must be properly stated in problem, etiology, and defining characteristics format. Note relationships by drawing arrows. Indicate
subjective data with S. Indicate objective data with an O. Make sure the goals are singular, client centered, measurable, etc. Give individualized interventions
with rationales. Make sure there are enough interventions to address and achieve the goal. Use additional paper as necessary.

Concept Map

Nursing Diagnosis/Etiology/Defining Nursing Diagnosis/Etiology/Defining

Characteristics: Chief Medical Diagnosis/and Characteristics:
pathophysiology:
Goal: Goal:

Interventions with rationales: Interventions with rationales:

Priority Assessments

Nursing Diagnosis/Etiology/Defining List which of this patient’s Nursing Diagnosis/Etiology/Defining

Characteristics: medications and diagnostic tests are Characteristics:
associated with the primary medical
Goal: diagnosis Goal:

Interventions with rationales: Interventions with rationales:

References: (List in APA format)

 Medical Surgical Nursing I
The Nursing Process

3. Evaluation: Reflect on your nursing goals. Were they accomplished in the time frame of your clinical day? Is it realistic? Do you need to modify any
of the goals? Can any goal be discontinued? Did any goal seen inappropriate and need to be completely revised?

4. Private Journal (submit in drop box provided) weekly on self reflection: What are your strengths and weaknesses in accomplishing this care plan? How
do you plan to strengthen your weaknesses? How did you feel about todays clinical? (Your skills, fellow students, staff, etc.)