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Student Name: _________________________________________ Dates of Care: _______________________


Client Initials: ________ Gender: _____ Age: ____ RM# _____ Med Team/MD: ___________________
Admitting Diagnosis: _______________________________________________ Date of Admission: __________________
Concurrent Diagnoses: ___________________________________
Surgery: ________________________ Date: ______________
Allergies to Drugs or Foods: _____________________ Advanced Directives / Code Status: ______________




  

Data Collection Day Clinical Day 1 Clinical Day 2

Vital Signs/SpO2: Frequency

I & O/ Fluid Restrictions


Diet

Scheduled Diagnostics

Activity Level

Dressing Change Orders

Resp. Therapy

Physical Therapy

Daily Weights

SCD, TEDS, CPM

Accuchecks
Daily Labs:

Other Treatments:


      
Doctor¶s Doctor¶s Nurse¶s Nurse¶s
Data Collection Day Data Collection Day #1 Data collection Day Data Collection Day #1
and or Day #2 and/or Day #2
Pathophysiology of Admitting Diagnosis:

Pathophysiology of Concurrent Diagnoses:

Description of Surgical Procedures:























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Labs/X-rays/Dx Normal Date Date Date Correlation to Pathophysiology: Interpret results as well as correlating
Tests Results Range Result Result Result with the client¶s medical condition:

#   


WBC 3.6-11.0
RBC 4.5-5.90 
Hg 13.5-17.5 
Hct 41-53 
Platelets 150-450 
ESR N/A

 







MCV 30-98
MCH 26-34
MCHC 31-37
RDW 12.0-14.6
Mean Platelet 6.8-10.2



Na 135-145
K 3.5-5.1
Cl 94-106
Glucose 60-100 
Total Protein 6.2-8.1 
Albumin 3.5-5.0 
CO2 20-29
BUN 7-25
Cr 0.7-1.60 
Calcium 8.2-10.3 

Bilirubin Total 0.2-1.2
Bilirubin Direct 0.0-0.4
ALT 0-35 
AST 0-38 
Mg 1.6-2.2
Phos 2.4-4.6 
Alk Phos 32-108
Lactic Acid 0.5-2.2
(Plasma)
Anion Gap 5-19 
 
 
 
INR 0.8-1.2
PT 22-37
PTT

$

 
Clarity ------
Color -----
Bilirubin Negative
Blood Negative
Glucose Negative
Ketones Negative
Leukocytes Negative
pH 5-8
Protein Negative
Sp Gravity 1.001-
1.035
Urobilonogin 0-1mg/dL

 

WBC 0-5 HPF
RBC 0-5 HPF
Epithelial 0-5 HPF
Bacteria 0-450
HPF
Casts 0-1

$
Amphetamine Negative
Barbituate Negative
Benzodiazapine Negative
Cannabinoids Negative
Opiates Negative
PCP Negative
Cocaine Negative
%
#  
pH 7.35-7.45 
PCO2 32-48
PO2 83-108 
O2 sat -----
HCO3 21.0-28.0 
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note source/growth and sensitivity
Exudate Culture """""""   
Gram Stain """"""""   

Fungal Calcaflour """"""""   



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X-Ray - Chest

Sonogram
Extremity

CAT Angiograph

()  


  
   describe results
Vancomycin ------
Level
Blood Antibody
Screen
*  
Hep B- Antigen Non Reactive

Hep B- Antibody Non Reactive

Hep A Non Reactive

Hep C Non Reactive


Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u u

u u
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u

u
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u

u
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u u

u u
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u u

u u
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
u u

u u

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Level of Consciousness: Motor Strength: 0 = complete paralysis, 1= flicker of Respiratory Rate: ____
Alert: Oriented: Confused: Lethargic: movement, 2 = overcome gravity, 3 = 50% of normal Pattern: _____ Normal _____ Shallow _____
Unresponsive: to Verbal stimuli Y N 4= 75 % of normal strength, 5= 100% of normal Rapid_____ Labored_____
Painful Stimuli: Y N strength Cough: Non ±Productive ___ Productive ___
Glasgow /coma Scale Rating (if needed) ______ RUE ____ LUE ____ RLL ____ LLE ____ Describe:___________________________________
Disoriented: Person Place Time ___________________________________________
Behavior: _________________________ Describe:__________________________
Chest inspection (expansion, deformitiesm: _________
Communication/Speech Pattern: ______________ Mobility: ____________________________ ___________________________________________
___________________________________________ ___________________________________________
Pupil size: Rt. ______ Lt. ______
Reaction: __________ ROM - L= Limited Use of accessory muscles: yes ___ no: __
Vision Impairment: Y N Lung Sounds: 1 = clear, 2 = diminished, 3 = crackles,
Activity/ Restrictions: _________________________ 4 = rhonchi, 5 = wheezing, 6 = friction rub.
Describe: ___________________________________ ___________________________________________
RUL ___ RML __ RLL _____ LUL ___
Glasses: Y N Risk for Fall: : Y N LLL_____

Sensation: Intact Losses Use of Assistive Devices: O2 saturation: Room Air:___ ______
Describe:___________________________________ ___________________________________________ On Oxygen Therapy:________
___________________________________________
Hearing loss: : Y N ______________________________
Describe:___________________________________

History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Sedative medications

Possible Nursing Dx:


Possible Nursing Dx: Possible Nursing Dx:


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Apical pulse: ____ Abdomen: distended non-distended Patterns: continent ___ incontinent ___ nocturia___
Rhythm: regular irregular Bowel Sounds: describe as A = absent, N = normal, ___ frequency ___ urgency ___ dysuria _____
Heart Sounds: Aortic _____Pulmonic ______ HA= hyperactive, HO= hypoactive urinary retention ___
Tricuspid _____Mitral ______ ___ RUQ ___RLQ ___LUQ ____LLQ
Describe abnormalities: ______________________ Appearance: clear ___ cloudy ___yellow
___________________________________________ Last BM: __4/10/11___(date) ___ pink ___ amber ____bloody____
diarrhea _____ constipation ____ normal__x___
Capillary Refill: < 3sec > 3 sec. Catheter: : Y N
Ostomy: Y N Type-____________________________________
Pulses: describe as 0 = absent, 1 = doppler, 2 = weak, Type/describe fistula: _________________________
3 = normal and 4 = bounding __________________________________________ 24 hour I&O______________________________

___RR __LR ____RDP ___LDP ___ RPT ___LPT N/G decompression: : Y N


Describe:
Dialysis Shunt: : Y N Condition: _______ ___________________________________________
___________________________________________ ___________________________________________
Feeding tube/PEG: : Y N
Homan¶s sign: ____ Positive ____ Negative N/A Feeding type/rate: ____________________________
Patency/Residual:____________________________
Edema: describe as 0=none, 1+= barely detectable, 2+
indentation, 3+ indentation, 4+ indentation = > 10mm History or current alterations affecting this system: History or current alterations affecting this system:

RUE ____ LUE ____ LLE ____ RLE _____


Periorbital_____ Sacral______

JVD: : Y N

History or current alterations affecting this system:

Possible Nursing Dx:


Possible Nursing Dx:
Possible Nursing Dx:
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Temp: ___warm, ___hot, ___cool Adm. Weight: ________ Type of Pain: Acute______ Chronic____
Moisture: ___dry, ___moist, ___diaphoretic Current Weight:_______ 
Color: ___normal, ___ pale, ___ cyanotic, ___ Ideal Body Weight:____ Location: ________________________
flushed ___ History of Weight loss: ________________________
Other (describe)______________________________ ___________________________________________ Intensity/Rating:_____________________________
Skin Condition:_____normal__________________
___________________________________________ Diet History: ___ _____________________ Pattern: ____________________________________
___________________________________________
Incision/wounds:(describe)_____________________ ___________________________________________ Nature : ______________
___________________________________________ ___________________________________________
___________________________________________ Appetite:____ _________________________ ___________________________________________
___________________________________________
Dressing Percent of meal eaten: Breakfast:________
Orders:______________________________ Lunch:_________ Dinner: _________
___________________________________________ Snacks:_____________________________________
___________________________________________
Describe condition of teeth/denture/oral mucosa:
Braden Scale Score: _____ ___________________________________________
PUSH Tool Score: __________ ___________________________________________
___________________________________________
Other: _____________________________________

Blood glucose monitoring:


Reading/time ______________
Reading/time_____________

History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:

Possible Nursing Dx:


Possible Nursing Dx: Possible Nursing Dx:

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Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:


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History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:

Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:


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Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:

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Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:


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Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:


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History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:

Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:

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Stressors: Behaviors/Coping Strategies

Identified culture/ethnicity Religion Occupation Family Role

Developmental Task: Understanding of Illness/Treatments


Clients Developmental Task According to Erikson:
Describe if the client has/has not achieved their developmental task.
Include positive/negative resolution and justify your conclusion.

Community Referral
Psychosocial Diagnosis:








Nursing Dx Priority_1__
Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)

Nursing Diagnosis/Analysis: u u

Correlation to Patho or Psycho-physiology

Discharge Goal: Teaching Plan:


Nursing Dx Priority___ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)

Nursing Diagnosis/Analysis:

u u .

Correlation to Patho or Psycho-physiology

Discharge Goal: Teaching Plan:


Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)

Nursing Diagnosis/Analysis:

u u

Correlation to Patho or Psycho-physiology

Discharge Goal: Teaching Plan:


Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as g
C: collaborative/interdependent partially met)

Diagnosis/Analysis:

u u

on to Patho or Psycho-physiology

e Goal: Teaching Plan:.