Name: Date: 1
Patient Profile Worksheet: Part 1
Clinical Date: __ / __ / __
A. Personal Information
Room # __ Gender __ Ethnicity __ Age if <90 __
Place of Residence: __ MD __
Emergency Contact: __ Marital Status __
Admitting Diagnosis & any additional current diagnosis: __
Co-Morbidities: __
Date of Admission: __ Date of Surgery: __ Allergies: __
Code Status: __ Mental Status: __
B. Activity and Nutrition
Diet order: __ Route/Rate if enteral: __ Last Wt: __
Level of Activity (bedrest, up ad lib, BRP, turning): __
Level of self-care: __
C. Nursing Care
Drainage devices (foley, NGT, JPs, T-tube, etc.): __ NGT Flushes: __
Wound care/Dressing (be specific): __
IV access (peripheral, central, location, care): __
IVF: __ @ __ mL/hr Saline Lock? __ TPN? __
Frequency of vital signs (including pulse oximetry): __
Frequency of Glucometer: __ Supplemental oxygen: __ OSA __
Falls Risk __
Precautions: __
Most Recent Labs
Lab Normal range Patient value Date/time High/Low
CBC
WBC 4.5-11.1 x103µL
RBC 3.71-5.81 CU
Hb 11.7-17.4 g/dL
Hct 33-52%
MCV 77-103 fL
MCH 26-35 pg/cell
MCHC 32-36 g/dL
Plts 165-450 x103µL
CHEM 12
Na+ 135-145 mEq/L
K+ 3.5-5.3mEq/L
Cl- 97-107 mEq/L
CO2 22-26 mEq/L
Anion Gap 8-16 mmol/L
Glucose-fast <100mg/dL
BUN 8-21 mg/dL
Creatinine 0.51-1.21 mg/dL
Calcium 8.2-10.2 mg/dL
Total protein 6-8 g/dL
Albumin 3.7-5.1 g/dL
AST 10-40 units/L
Total bilirubin <1.2 mg/dL
OTHER LABS
(EBSCO, 2020)
Diagnostic Tests
Diagnostic Study Date & Time Results
2
(Cardiac, Pulmonary, Radiological, other)
Vital Signs – 3 most recent
Date/Tim
e
Temp HR RR BP SpO2 Pain
PATIENT HISTORY
Chief complaint:
History of Present Illness:
Past Medical History:
Past Surgical History:
Family History:
Tobacco __ Alcohol __ Illegal Drugs __
Occupational Status __
Religious Preference __
Cultural Support Needs __
Plan for Shift Care
Prioritize the Hypothesis:
3
Patient care priority for shift (List top priority issue based on ABC. What is the patient care
priority for the shift?) __
Recognize and Analyze Cues:
What information from the worksheet part 1 lead you to choose this priority? __
Generate Solution:
Desired patient outcome for the shift (using priority above) __
Take Action:
List three interventions for this shift that will your help patient to attain this desired outcome __
Evaluation of Outcome:
How will the patient be evaluated to know that they have attained the desired outcome __
4
MEDICATION LIST
Medication
(Generic &
Trade)
Route Dosage &
Frequency
Category/MPOA Use for this specific
patient
(Why is this specific
patient receiving this
specific medication?)
Potential Side Effects
for this Patient
(List up to 5 possible s/e for
which you will monitor this
specific patient.)
Nursing Implications:
Pre-administration
(What will you do prior to
administration?)
Nursing Implications: Post-
administration
(What cues will indicate this medication’s
positive effect?)
Trade
(Generic)
(Vallerand & Sanoski, 2019)
5
Patient Profile Worksheet: Part 2
PHYSICAL ASSESSMENT
GENERAL: (overall assessment)
Click or tap here to enter text.
HEENT: (ED only)
Click or tap here to enter text.
CARDIAC: (heart sounds, rate, rhythm, pulses, circulation, etc)
Click or tap here to enter text.
RESPIRATORY: (lung sounds, work of breathing, O2 sat)
Click or tap here to enter text.
ABDOMEN/GI: (bowel sounds, overall assessment)
Click or tap here to enter text.
GU: (urinary output, catheters, etc.)
Click or tap here to enter text.
MUSCULOSKELETAL: (strength, gait, mobility status)
Click or tap here to enter text.
INTEGUMENT: (list any wounds, dressings, other issues)
Click or tap here to enter text.
6
NEURO: (A&O x 4, pupils, etc.)
Click or tap here to enter text.
7
Student name:
Pre-Care Assessment Nursing Diagnosis Planning and Evaluation Implementation
Recognize Cues
Data that you gathered from
your assessment and chart
review that will guide your
ongoing care of this patient.
Subjective and objective
information. Examples:
Abnormal Labs, abnormal
diagnostic tests, and abnormal
assessment findings. What is
the proof you have selected
the correct nursing dx?
Analyze Cues to
Prioritize Hypothesis
For each nursing
diagnosis include:
1) “Actual” vs “Risk for”
2) Nursing diagnosis
3) r/t statement
Desired Patient Outcomes (Goals)
and Post-shift Evaluation
Take Action
List 2 Nursing Action
Interventions.
Do not use assessments.
1 1. Goal #1:
The patient will:
within __ hours.
_______________________
Post-shift evaluation:
Goal evaluation:
__ met
__ progressing
__ not met (no progress)
__ discharged
Supporting assessment data:
1a. The nurse will:
Timeframe:
Rationale:
1b. The nurse will:
Timeframe:
Rationale:
8
Goal #2:
The patient will:
within __ hours.
____________________
Post-shift evaluation:
Goal evaluation:
__ met
__ progressing
__ not met (no progress)
__ discharged
As Evidenced by:
2a. The nurse will:
Timeframe:
Rationale:
2b. The nurse will:
Timeframe:
Rationale:
(Ackley, et al., 2017)
9
10
Title
Student Name
School of Nursing, Liberty University
Course #: Course Name
Instructor Name
Date
ov
11
Pathophysiology
12
References
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: An evidence-
based guide to planning care. Elsevier.
Vallerand, A. H., & Sanoski, C. A. (2019) Davis’s drug guide for nurses (16th ed.) FA Davis.
