correct

Student

Date

Instructor

Course

Patient Initial

Unit/ Room#

DOB

Code Status

Height/Weight

Allergies

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

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

History of Present Illness & Chief Complaint:

Admission Diagnosis:

Admitting dx: Left intertrochanteric hip fracture, pain

Explain what a left hip fracture is

GENERAL:

HEENT:

CHEST:

HEART:

LUNGS:

ABDOMEN:

PELVIS:.

UPPER EXTS:

LOWER EXTS

NEUROLOGIC:

SKIN:

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

Diagnostic testing: abnormal Left hip xray

Labs:

Hematology: Hb 14, HCT 42, Platelets 195, WBC 8, RBC 4.3

-all within normal range

Electrolytes: K+ 3.8, Na 142, Creatnine 0.8, Cl- 101, BUN 20, HCO3- 24, Calcium total 8.6

-all within normal range

Past Medical (Pathophysiology of medical diagnoses):

Surgical History:

Medical hx: Diagnosed with osteoporosis 10 years ago in 2011

Explain pathopysiolgy of osteoporosis

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

Religion: Christian

Social background: White, female, English speaker, widowed, mother of 1 daughter, lives with daughter

-

Concerns:

-depression

- need of assistance at home

-

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

At risk for: loss of physical function

- perform active range of motion 2 a day

-

-

Rick for skin integrity

-

Consults/ discharge referrals: Orthopedic consult, physical therapy, social worker

Orders: take pain medication prn

Diet: n/a

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

impaired physical mobility related to ROM

1.

2.

3.

4.

1.

2.

3.

4.

Risk for pressure ulcer

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