Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Code Status:
Parents or Guardian:
Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Code Status:
Parents or Guardian:
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL? (USE SEPARATE SHEET WHEN NEEDED)
Medical History:
PAST DIAGNOSED MEDICAL PROBLEMS
Surgical History:
PAST DIAGNOSED SURGICAL PROBLEMS
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL? (USE SEPARATE SHEET WHEN NEEDED)
Medical History:
PAST DIAGNOSED MEDICAL PROBLEMS
Surgical History:
PAST DIAGNOSED SURGICAL PROBLEMS
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Chief Complaint
Admitting Diagnosis & Admission Date
Chief Complaint
Admitting Diagnosis & Admission Date
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage with real examples (based on objective assessment)
Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage with real examples (based on objective assessment)
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)
❋Economic Stability
❋ Education -school
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Parents-Who takes care of the child at home?
Siblings
Extended Family
(based on objective assessment)
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)
❋Economic Stability
❋ Education -school
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Parents-Who takes care of the child at home?
Siblings
Extended Family
(based on objective assessment)
Concept Map
Student Name:
Instructor:
Date of Care:
Concept Map
Student Name:
Instructor:
Date of Care:
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
MEDS
TREATMENT
REFERRALS NEEDED-
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
MEDS
TREATMENT
REFERRALS NEEDED-
Medical Management and Collaborative Plan
(from MD, PT, OT notes)
Medical Management and Collaborative Plan
(from MD, PT, OT notes)
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): Patient’s age, Parents Present, LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): Patient’s age, Parents Present, LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal Ranges
Admission Lab Values
Current Lab Values
Explain Abnormal Labs R/T Your Pt
INCLUDE: Appro. Diagnostic Tests/ Procedures- DATEs and RESULTS
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal Ranges
Admission Lab Values
Current Lab Values
Explain Abnormal Labs R/T Your Pt
INCLUDE: Appro. Diagnostic Tests/ Procedures- DATEs and RESULTS
Concept Map
Student Name:
Instructor:
Date of Care:
Concept Map
Student Name:
Instructor:
Date of Care:
Medications & Allergies (2)
Medication Name
Dose –
Show math with mg/kg for your patient’s weight
Route
Freq.
Indications (PRN meds must include MD ordered Indication)
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing
Considerations
RN Considerations
Medications & Allergies (2)
Medication Name
Dose –
Show math with mg/kg for your patient’s weight
Route
Freq.
Indications (PRN meds must include MD ordered Indication)
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing
Considerations
RN Considerations
Respiratory (7)
Respiratory (7)
Cardiovascular (6)
FOCUSED
Cardiovascular (6)
FOCUSED
Vital Signs (4)
INSPECTION
Vital Signs (4)
INSPECTION
Neurological (5)
HEAD
Neurological (5)
HEAD
ASSESSMENT/
REVIEW OF SYTEMS
ASSESSMENT/
REVIEW OF SYTEMS
Concept Map
Student Name:
Instructor:
Date of Care:
Concept Map
Student Name:
Instructor:
Date of Care:
Musculoskeletal
(8)
PALPATION
ASCULTATION
-OR-
Musculoskeletal
(8)
PALPATION
ASCULTATION
-OR-
GI
Hydration/Nutrition (9)
TO
TOE
GI
Hydration/Nutrition (9)
TO
TOE
GU (10)
ASSESSMENT
GU (10)
ASSESSMENT
Rest/ Exercise (11)
Rest/ Exercise (11)
Misc.
Misc.
Psychosocial (14)
Psychosocial (14)
Endocrine (13)
ASSESSEMENT
Endocrine (13)
ASSESSEMENT
Integumentary (12)
ASCULTATION
PALPATION
Integumentary (12)
ASCULTATION
PALPATION
Priority Nursing Diagnosis #1
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics
Priority Nursing Diagnosis #1
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics
Priority Nursing Diagnosis #2
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics___________
Priority Nursing Diagnosis #2
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics___________
Concept Map
Student Name:
Instructor:
Date of Care:
Concept Map
Student Name:
Instructor:
Date of Care:
PLAN OF CARE
PLAN OF CARE
Evaluation #1
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
Evaluation #1
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
Intervention #1
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
(Enough to accomplish the Goal)
Intervention #1
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
(Enough to accomplish the Goal)
At Risk Dx.-
PT AT RISK FOR…
Nsg Dx R/T _______
At Risk Dx.-
PT AT RISK FOR…
Nsg Dx R/T _______
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
At Risk Interventions
(TO PREVENT BECOMING ACTUAL PROBLEM)
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
At Risk Interventions
(TO PREVENT BECOMING ACTUAL PROBLEM)
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
At Risk Outcomes/
Goal
S-STATES, PRESENTS, WILL BE ABLE…
M-AMOUNT, NO. OF TIMES…
A-TTAINABLE
R-EALISTIC
T-w/IN THE HOUR(S), BY END OF SHIFT, BY DISCHARGE DAY
At Risk Outcomes/
Goal
S-STATES, PRESENTS, WILL BE ABLE…
M-AMOUNT, NO. OF TIMES…
A-TTAINABLE
R-EALISTIC
T-w/IN THE HOUR(S), BY END OF SHIFT, BY DISCHARGE DAY
Evaluation #2
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
Evaluation #2
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
At Risk Evaluation Plan
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET and possible revision of plan)
At Risk Evaluation Plan
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET and possible revision of plan)
Interventions # 2
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
(Enough to accomplish the Goal)
Interventions # 2
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update MD/PA/NP
(Enough to accomplish the Goal)
(VM/GP/KL-V5)
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