Nursing Process Matrix Worksheet:

Student Name: ___Gregory Harrison_ Clinical Shift Date: ____

Total Patient Assignment; Clinical Judgment Focused Assessment Prioritization, Immediate Nursing
Diagnosis, Current Clinical Measurement Model Systematical Prioritization of Delegation, Needs What do Achieved
Condition, Gender, Age, each section per individual Collaboration & you want to do Outcomes
Acuity Level & Code Status patient Safety Considerations for each
patient?

A. Dx: ETOH with history of I. RECOGNIZE CUES I. Nursing Priority Prioritize patient C A. make sure pt Y
alcohol abuse and neuropathy, What mattered most? A. Assess mental status and because he was gets to ECHO, and
condition was stable, 43 year (Priority) II. ANALYZE CUES transport to ECHO bleeding from his intial maintains npo
old female, alert and oriented What did it mean? B. Transport to nuclear medicine status
foley catherter, had a
x4 , full code C. irrigate bladder, start heparin
(Immediate follow-up) stage 4 ulcer on the
D. Hemodialysis medication
III. PRIORITZE HYPOTHESIS lower back and was
Where do you start? II. Immediate Action now verbal and had B. given insulin, Y except for
IV. GENERATE SOLUTIONS A. monitor hepatitis and liver generalized weakness, maintain npo pain control
_________________________ What can you do? B. review how the digestive needed to irrigate status, until
_ B. dx: colitis with history of (What do you anticipate?) system is handling food bladder to clear clots procedure,
fibromyalgia, seizures. V. TAKE ACTION C. remove clots and blockage remove access
and since blood was
Condition was stable (slightly What interventions will you D. keep the kidneys as healthy as from port before
collecting, he needed discharge
elevated bp and glucose), 41 do? VI. EVALUATE OUTCOMES possible
to be started on
year old female, DNR, alert Did it help?
and oriented x4 III. First Actions heparin and C. irrigate Y
Clinical Evaluation Framework (Hypothesis) transported to IR for iv bladder, get
Standard 1: Patient-Centered A. put in transport, filter placement. - blood levels,
Care Standard 2: Teamwork & monitor patient Delegated the task of assess
Collaboration B. assess pain, review gastric conciousness
cleaning blood off
Standard 3: Evidence-Based empty report
ground to na, asked
_________________________ Practice & Quality C. urology contacted
charge nurse to collect
_ C. Dx: hematuria, parkinson Improvement Standard 4: D. assess pt mental health and
feelings blood from pt B which
with history of stroke and Safety
was needed for a
clots. Patient was classified as Standard 5: Informatics IV. Anticipate Clinical procedure. Seizure D. give meds Y
total assist, unstable, 83 year Standard 6: Professionalism Outcomes precautions, aspiration,
old male, orientated only to
 A. Put in transport, review fall were all
chart for liver enzyme levels implemented
B. pain medication, insulin, low
cal diet
C. irrigation, cleaning, turning pt
self, DNR D. comfortable

_________________________
_ D. Dx: Chronic Kidney
Disease, pt awaiting
placement, stable, 73 year old
male, dnr, a&o x4

V. Nursing Interventions
A. give medication, assess vitals,
mental status
B. administer insulin and
medication, monitor diet
C. turn, clean, irrigate, round
frequently, aspiration
precautions, establish
communication due to being no
verbal, foley catheter placement,
transport to IR
D. give medication, encourage
verbalization of feelings

VI. Nursing Evaluation

A. request put in to go to
 vascular to assess for clots, pt
comfortable
B. pt in pain, discharged home
C. pt more comfortable, stablized,
iv filter placed to prevent clots to
brain
D. comfortable

Course Objectives

• Incorporate concepts, principles, theories and models from the natural and social sciences, the arts, the humanities, and the art and science of nursing to
guide clinical practice.

• Facilitate clinical judgment as the basis for nursing practice in providing and coordinating care for individuals, families, and communities across the life
span in health promotion, disease prevention, health restoration, and rehabilitation.

• Discuss application of clinical data and research findings to the implementation of care.

• Review means of interaction with other health care professionals, clients, and consumers, as an advocate, teacher, collaborator, communicator, manager,
and professional leader to plan, provide and evaluate essential health services for culturally diverse populations.

• Discuss practice within the legal and ethical parameters of professional nursing.

JOURNAL - Reflect on your shift and caring for multiple patients

Provide a response to the following questions.
MULTIPLE PATIENT ASSIGNMENT CONSIDERATIONS STUDENT NURSE RATIONALE & REFLECTION

1. Delegation focus: What was your thought process A patient had an altered mental status, bleeding, bladder was being blocked, and at risk for a stroke. He was
leading to the delegation decisions above prioritized, cleaning, getting food, putting in transport could be reported to the front desk or na. The blood
draw was done by the charge nurse who had the knowledge about ports and the patient.
2. Prioritization focus: What data did you use to health // life risk and comfort
determine patient prioritization?

3. Collaboration focus: What collaboration efforts Contacting urology, talking with GI doctors, getting report from Ir and ER
were made in providing care throughout the shift?

4. Cultural aspects focus: How did the cultural PT D, usually like to pray and go out in the sun throughout the day. So respecting his time and behaviors while
diversity of the patients impact your decision making? also keeping schedule was medication required some commmunication

5. Did you have sufficient knowledge and skills to Yes, except knowledge about rectourethro fistulas and iv filter placement to prevent clots from reaching the
manage the day? brain

6. In what aspect did you feel unprepared or Irrigation of the bladder. For the first time the urologist came and did it, and due to the amount of clots and
performed outside your scope of practice? blood it took much longer. I wasn’t sure when to stop irrigating because it seemed “endless”. The urologist said
it uually doesn’t go that long so that was a first time experience.

7. What would be your next step to be prepared? I feel more prepared now. I just know sometimes it may take longer if the bladder was never irrigated but I
need to learn the signs of further complications while irrgating it

8. What three things did you learn today? Irrigate a bladder, port access,

9. What did you do well today? Assessing, meds, cleaning, talking to pt and faulty, blood draw, pt care