Patient identifiers:

Age: Gender: Ht: Wt. Code Status:

Isolation:

Development Stage (Erikson): Give the stage and rationale for your evaluation

Health Status

Date of admission:

Activity level: Diet:

Fall risk (indicate reason):

Client’s description of health status:

Allergies: (include type of reaction)

Reason for admission:

Past medical history that relates to admission:

Socio-cultural Orientation

Religious, Cultural and Ethnic background with current practices:

Socialization:

Family system (support system):

Spiritual:

Occupation (across the lifespan):

Patterns of living (define past and current):

Barriers to independent living:

ALLERGIES:

Medications: List all medications by generic name (trade name), dosages, classifications, and the rationale for the medications prescribed for this client. Include major considerations for administration and the possible negative outcomes associated with this medication. Identify both of the following:

1: What the medication does to the body to the cellular level; 2: Why is the client taking the medication?

Medication Classification Dosage & Route Rationale Assessment

LAB VALUES AND INTERPRETETION

LAB

Range

Value

Value

MEANING (If WDL then explain the possible reason for the lab)

LAB

Range

Value

Value

MEANING

HEMATOLOGY

CHEMISTRY

CBC

Glucose

WBC

BUN

RBC

Cr

HGB

GFR

HCT

Na

PLATLETS

K

Diff:

CO2

Polys

Ca

Bands

Phos

Lymph

Amylase

Mono

Lipase

Eosin

Uric Acid

GBC indices

Protein

MCV

Albumin

MCH

Cl

MCHC

Enzymes

COAGs

LDH

PT

CPK

INR

SGOT

PTT

SGPT

ABGs (V or A)

Troponin I

PH

Myoglobin

PCO2

PO2

Cholesterol

BASE EX:

SAT:

URINALYSIS

Range

Value

Value

Meaning

Others not listed:

Findings

Meaning

Color

Gastroccult

Clarity

Hemoccult

Sp. Gravity

pH

EKG

Protein

Glucose

CT Scan

Ketones

Bilirubin

Occ. Blood

MRI or MRA

Urobilinogen

WBC

RBC

Epithelia

Ultrasound

WBC

RBC

Epith Cell

Bacteria

Hyaline Cast

Gran Cast

Bedside Procedures:

Leukocytes

Nitrite

ACCUCHECKS

Additional information:

Universal Self-Care Deficits: ASSESSMENT: (Highlight all abnormal assessment findings)

Vital Signs

Time:

Time:

Oxygenation/ Circulation

Intake:

SpO2

1. 2. 3.

Accu-check

1. 2. 3. 4.

Output:

Cardiovascular Assessment

Specialty devices:

Teaching needs:

Heart Sounds:

Skin Temp/Moisture/Color:

Edema: JVD:

Peripheral Pulses:

Pain assessment (OPQRST)

Rating:

Location:

Respiratory Assessment

Special devices:

Oxygen:

Teaching Needs:

Lung sounds:

Anterior:

Posterior:

Respiratory effort: Respiratory pattern: Reg/Irreg

Cough:

Respiratory treatment:

Medication(s):

Frequency:

Rationale for use:

Neurological Assessment:

Assistive devices :

Teaching Needs:

Level of Consciousness: Alert / Verbal / Pain / Unresponsive

Orientation: Person / Place / Time / Events

Fine motor function:

Gross motor functioning:

Sleep patterns (During admission):

Sleep patterns (at home):

GI Assessment:

LBM (include description):

Teaching needs:

Abdominal Assessment: (observe – auscultate – palpate)

Alteration in eating or elimination patterns:

Nutrition Metabolic Assessment:

% diet taken:

Alternative nutritional methods:

GU assessment:

Teaching needs:

Last void:

Due to void:

Alternative urinary elimination method: (if urinary catheter in place, when inserted)

Bladder scan

Assessment of urinary patterns:

Urine assessment (color odor concentration etc.)

LMP

Integumentary Assessment:

Teaching needs:

Color/ Mucous membranes

Hydration:

Wound Care:

Condition of skin:

Nutritional Assessment:

Teaching needs:

Diet:

Eating patterns:

Insulin administration:

Treatment of hypoglycemia:

Alternative feeding patterns:

IV Therapy

IV fluids infusing:

Rate:

Tubing dated?

IV Site Assessment: Location

Date of insertion: Change (site or dressing)

IV removal:

Reason for removal:

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom)

Manifested by: (Specific symptoms)

Short term goal : Create a SMART goal that relates to hospital stay.

Long term goal : Create a SMART goal that is appropriate for discharge.

This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)

Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)

Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?

NANDA NURSING DIAGNOSIS use NANDA definition

Expected outcomes of care (Goals)

Interventions

Patient response

Goal evaluation

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom?)

Manifested by: (specific symptoms)

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

This is specific to the client that you are caring for. A list of planned actions that will assist the client to achieve the desired goal. (i.e., obtain foods that the client can eat/ likes)

Identify what the client’s response or “outcome is to the goal or care that you have provided. i.e., client ate 45% of lunch)

Was it met? Not met? Partially met? If only partially met, what adjustments need to be made?