assign

Student

Date

Instructor

Course

Patient Initial

Unit/ Room#

DOB

09/20/1935

Code Status

Full code

Height/Weight

152cm/47.6kg

Allergies

No known

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

99F/ oral

90bpm/ radial

15bpm

97

134/80

2/10

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

Enoxaparin sodium

Anticoagulants

subcutaneous

daily

40

Docusate sodium

Laxatives, Stool Softener

oral

daily

100

Morphin

Opiate, narcotic

IV

PRN every 4 hrs

4