Pt.

_____________________________________ Code _____________________ Age _____________ Student ____________________________________________ Day 1

Diagnosis ________________________________________ Surgery ________________________________ Activity Order ___________________ Allergies ______________________________

1430 1600 1700 1800 1900 2000 2100 2200

□ Check Orders/ □All Meds available □ Meds □Meds □Meds □ Meds □Meds □ Meds
progress Nts.for □Sign/Check med sheet □ Treatments □Treatments □Treatments □ Treatments □Treatments
changes. T ___________________
Lab results □ Treatments
P ___________________
□ Check Mar for _________________ T __________
R ___________________
new times/meds □ _______ □ _______ P __________
B/P______________
_________________ R __________
Pain ____________
Notes from report B/P ________
O2Sat ___________
_________________ Pain _______
□Rm Air
□Nasal Cannula
_________________
□ Meds to be given VS O2Sat _____
Accucheck ___________ □ _______ □ _______ Accucheck □Report off
Lab tests ____________
Diet ordered _____ □Charting
Treatments ___________ □Meds given ___________
IV sol. ______________ ______________________
% ______ cc ______ Intake _______ □Sign all
Output _______ meds
Rate ________________ □ Focused Assessments □ _______
Type of VAD: □ _______ NG _______
HS Care
LIB: Treatments
______________
Pt. _____________________________________ Code _____________________ Age _____________ Day 2
Diagnosis ________________________________________ Surgery Date ____________________________ Activity Order _____________ Allergies _____________________

1430 1600 1700 1800 1900 2000 2100 2200

□ Check Orders/ □All Meds available □ Meds □Meds □Meds □ Meds □Meds □ Meds
progress Nts.for □ Treatments
□Sign/Check med sheet □ Treatments □Treatments □Treatments □ Treatments □Treatments
changes. T ___________________ Lab results
□ Check Mar for P ___________________ _________________
new times/meds R ___________________ □ _______ □ _______ T __________
B/P__________________ _________________ P __________ □Report off
Notes from report Pain ____________ R __________ □Charting
O2Sat ___________ _________________ B/P ________ □Sign all meds
□Rm Air Pain _________
□Nasal Cannula _________________ □ _______ □ _______
O2Sat ________ Accucheck
Lab tests ____________ □ Meds to be given VS
Accucheck ___________ Diet ordered _____ __________
IV sol. ______________ □Meds given
Treatments ___________ % ______ cc ______ □ _______
Rate ________________ ______________________ Intake _______
□ _______
Type of VAD: □ Focused Assessments Output _______
HS Care NG _______

LIB __________________ Treatments

______________
Day 1: Form For Detailed Care Plan Only

1. NANDA: ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Pt. Centered Goal: _________________________________________________________________________________________________________________________

Pt. Expected Outcomes for today (3-4):

1. ___________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________________________

2. NANDA: ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Pt. Centered Goal: _________________________________________________________________________________________________________________________

Pt. Expected Outcomes for today (3-4):

1. ___________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________________________________

3. NANDA __________________________________________________________________________________________________________________________________
Day 2: Form for Detailed Care Plan Only

1. NANDA: ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Pt. Centered Goal: _________________________________________________________________________________________________________________________

Pt. Expected Outcomes for today (3-4):

1. ___________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________________________

2. NANDA: ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Pt. Centered Goal: _________________________________________________________________________________________________________________________

Pt. Expected Outcomes for today (3-4):

1. ___________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________________________________

3. NANDA __________________________________________________________________________________________________________________________________
 PATHOPHYSIOLOGY CONCEPT MAP
EXPECTED DIAGNOSTIC TEST/RESULT & PATHOPHYSIOLOGY ALL SIGNS AND SYMTPOMS
PATIENT RESULTS HIGHLIGHT PATIENT SIGNS &
HIGHLIGHT PATIENT RESULTS SYMPTOMS
Etiology:
Risk Factors:
 PATHOPHYSIOLOGY CONCEPT MAP
EXPECTED DIAGNOSTIC TEST/RESULT & PATHOPHYSIOLOGY ALL SIGNS AND SYMTPOMS
PATIENT RESULTS HIGHLIGHT PATIENT SIGNS &
HIGHLIGHT PATIENT RESULTS SYMPTOMS
Etiology:
Risk Factors:
 PATHOPHYSIOLOGY CONCEPT MAP
EXPECTED DIAGNOSTIC TEST/RESULT & PATHOPHYSIOLOGY ALL SIGNS AND SYMTPOMS
PATIENT RESULTS HIGHLIGHT PATIENT SIGNS &
HIGHLIGHT PATIENT RESULTS SYMPTOMS
Etiology:
Risk Factors:
AIR INTEGUMENTARY (Oral mucosa, Color, Temperature, Moisture, Turgor, Lesions, Pruritus, Dressings, Wounds, Incisions, Drainage, Erythema, IV site)
RESPIRATORY (Rate, rhythm,depth, lung sounds, SOB, O2, Cyanosis/nail beds, TCDB, Spirometer, Tracheotomy, Cough, Sputum appearance)
CARDIOVASCULAR (Apical pulse rate and rhythm, Blood pressure)
Peripheral Vascular (Venous Distention -JVD, Peripheral Pulses, Edema, Calf Tenderness, , Capillary refill, pain & paresthesias)
Data Gathering/ Diagnostic Tests Narrative Assessments Pathophysiology Nanda
PT _________ CBC Airway Clearance ineffective
PTT________ WBC__________ Aspiration risk for
INR_________ RBC__________
Breathing Pattern, ineffective
HbB__________
Suffocation, risk for
ABGs HCT__________
Skin integrity, impaired
pH _________ MCV__________ Skin integrity, impaired Risk
pC02________ MCH__________ Tissue Perfusion______
P02_________ MCHC_________ Altered
HCO3________ Retic __________ Dysreflexia
Os Sat _______ Knowledge Deficit
FIO2 _________ Sed Rate _______ ___________
BE __________ Platelets ________ Non-Compliance
Pain Acute/Chronic
THYROID Differential
Free T4 _____
T4 ________ Neutrophils ________
T3 Uptake _____ ANC _____________
T7 ___________ Bands/Segs ________
TSH _________ Eosinophils ________
Gentamycin Basophils __________
Peak ________ Lymphocytes _______
Trough ______ Monocytes _________
Theophylline
Level _______ BNP ______________
Troponin ___________

CPK-MB ____________
EKG

Chest X-ray

C&S Sputum:
- culture
FOOD / WATER ( Diet type, percent eaten, tolerance, IV, swallowing, weight (gain or loss)
Gastrointestinal Elimination (Bowel sounds, abdominal distention, palpation, last BM, frequency, pattern, ostomy, nausea, vomiting, flatus, tubes)
Genitourinary ELIMINATION (Urine color, amt, voiding pattern, catheter, dialysis, odor, penile or vaginal discharge, 24 hour I&O)
Data Diagnostic Tests Narrative Assessment Pathophysiology Nanda
Gathering
LIVER TEST RENAL TEST Fluid Volume deficit
BUN ___________ Fluid Vol Deficit; Risk For
Alk phos_______ Fluid Volume Excess
LDH __________ Creatinine_______ Nutrition altered Less /
ALT __________ Uric Acid ________ Greater
AST __________ Than body requirement
ELECTROLYTES Oral Mucosa membrane
Ammonia_______ Swallowing Impaired
Potassium _______
GGT __________ Sodium _________ Infant feeding pattern
T. Protein ______ ineffective
Calcium ________
Albumin ________ Breast Feeding
Magnesium ______
Globulin _______ ____________
Chloride_________
Incontinence: Type
A/G Ratio ______ CO2____________
_________
T. Bili _________ Phos ___________
Urinary Elimination, altered
Serum Iron ______
Amylase _______ Pattern
Ferritin __________
Fasting Bl Sugar Urinary Retention
TIBC ___________
_______________ Self care deficit: toileting
Finger stick Bl Bowel Incontinence
Constipation
Sugar ________ URINALYSIS
Constipation: Perceived /
Specific Gr._______
Colonic
Cholesterol_____ pH______________
Diarrhea
Triglycerides____ Protein__________
Pain acute / chronic
Glucose_________
HDL __________ Knowledge Deficit_________
WBC ___________
LDL ___________ Non-compliance
RBC____________
VLDL __________ Bacteria_________
Mucous Threads___
PKU ___________ Crystals__________
Nitrates __________
Stool Leukocyte esterase
Occult Blood ______ ________________
Stool
O & P ___________ OB __________
O&P ______________
X Rays
Normalcy PSYCHOSOCIAL (Behavior, emotions, anxiety, depression, anger, thought disturbance, judgment,
insight into illness)

Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology/ Psychological Theory NANDAs

Anxiety
Ineffective patient/family coping
Drug Levels: Powerlessness
Spiritual distress
Grieving
Body image disturbance
Pscyh Consult: Social isolation
Confusion, acute/chronic
Knowledge deficit R/T ______
Non-compliance

MUSCULOSKELETAL (Activity level, ADL, gait, assistive devices, extremity movement, CMS of involved
Activity/Rest extremity,
PAIN (Location, quality, scale 1-10)
SLEEP (Pattern, remedies)
NEUROLOGICAL (LOC, orientation, PERRL, memory, numbness, tingling, tremors, sensation, Best
Verbal Response, Best Motor Response, Eyes Open—NO NUMBERS FOR GLASCOW COMA SCALE)

Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology NANDAs

Fatigue
Serum drug levels:
Activity intolerance
Mobility, impaired
Diversional activity deficit
Peripheral neurovascular
dysfunction
Sleep disturbance
Thought process, altered
Disuse syndrome
Memory, impaired
X-rays: Confusion, acute/chronic
Infant behavior ___________
Knowledge deficit R/T ______
Non-compliance __________
Pain, acute/chronic
 Special senses exam) vision, hearing, taste smell), discomfort, sexuality, menses, vaginal drainage (lochia), breast, fundus of
Solitude and Social Interaction uterus, history of pregnancy
Social skills, coping skills assets and strengths, communication content and speech pattern

Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology NANDAs

Thought process, altered
ELISA __________
Sensory perceptual alteration
CD4 ____________ Impaired verbal communication
Sexual dysfunction
VDRL__________
Knowledge deficit R/T ______
FSH____________ Non-compliance __________
ESTROGEN_____
PSA____________
CA-125 _________
CEA ___________
Other tumor
markers ________

Hazards SUBSTANCE ABUSE (Specify level of use)( ETOH, drugs, tobacco, etc)
SAFETY (Restraints)

Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology NANDAs

Ineffective individual coping
Blood alcohol
Ineffective family coping
Risk for self-mutilation
Non-compliance
Knowledge deficit R/T ______
Drug levels

Pack per year:

Developmental SCR Developmental tasks, adjustments related to aging, parenting behaviors, experiences that impact human development, grieving
process
Weight (pounds/kilograms and percentile), length/height (inches & percentile), head circumference (inches & percentile)

Data Gathering/Diagnostic Tests Narrative Assessment Deficits / Nursing Interventions NANDAs

(Maturational/Situational, Physical & Growth & development, delayed
Erickson’s Stage:__________________
Cognitive) Parenting, altered, potential for
Coping, family, altered/ineffective
Conflict, parental
Describe Erickson’s DSCR task:
Role performance, altered
Knowledge deficit R/T ______
Situational low self-esteem

Piaget stage: _______________

Describe Piaget’s task:

See page 92 for Stages and Tasks.

GROWTH HORMONE _________

__________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses #1
__________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses #2
__________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses # 3

Assessment Prioritized Client Goals, Desired Nursing Interventions (NIC) Evaluation

(USCR, DSCR, Nursing Diagnosis Outcomes & Time Client Nurse Responsibilities with
Frame Responsibilities times; Include Rationale
HDSCR) (highlighted with source)
Effectiveness of
SCR : ___________ Client Goal / Time . Nursing
Fame Interventions
1.

2.

3.

As Evidenced By: 4.

5.

Goal Accomplished

a.
Dx studies :
b.

c.

Suggested Revisions
______________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses #1
______________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses #2
______________________________________________________________________________________________________________________________________________
Nursing System Prioritized Nursing Diagnoses #3

Assessment Prioritized Client Goals, Desired Nursing Interventions (NIC) Evaluation

(USCR, DSCR, Nursing Diagnosis Outcomes & Time Client Nurse Responsibilities with
Frame Responsibilities times; Include Rationale
HDSCR) (highlighted with source)
SCR: ____________ Effectiveness of
Client Goal / Time . Nursing
Fame Interventions

1.

2.

3.
As Evidenced By:
4.

5.

DX Studies : Goal Accomplished

a.

b.

c.

Suggested Revisions
Put a  next to medications related to this admission. Height________________________Weight_______________________
MEDICATIONS (Oral, IM, SQ, IV, topical, etc.) Allergies:
Medication Classification/Action Five Rights and Indication for Labs/Parameters Major Side Effects/
Trade/Generic Compatibility THIS Client to be checked Nursing Implications
(List both)
1 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
2 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
3 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
4 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
5 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
Put a  next to medications related to this admission. Height________________________Weight_______________________
MEDICATIONS (Oral, IM, SQ, IV, topical, etc.) Allergies:
Medication Classification/Action Five Rights and Indication for Labs/Parameters Major Side Effects/
Trade/Generic Compatibility THIS Client to be checked Nursing Implications
(List both)
1 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
2 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
3 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
4 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
5 Dosage_____________
Route______________
Frequency___________
AC PC c meals
Safe Dose: Y N
Crush: Y N
Compatible: Y N
 Detailed Client Care Plan
Student: Date: __________

Client Initials: Sex: Age: Weight_____ Code Status:_____________________________________

Diagnosis:_____________________________ Cultural Influences: ___________________________

Surgery: date________ type_________________________________________________________________

History of Present Illness Past Medical History

Definition, Etiology, Abbreviations/Risk Factors Client Etiology/Risk Factors

Definition: Smoking # Pack Yrs._______ ETOH/Drugs________________

Abbreviation:
Pt.Etiology:
Etiology:

Pt. Risk Factors:

Risk Factors: