Pt. _____________________________________ Code _____________________ Age _____________ Student ____________________________________________ Day 1 Diagnosis ________________________________________ Surgery ________________________________ Activity Order ___________________ Allergies ______________________________ 1430 1600 1700 1800 1900 2000 2100 2200 □ Check Orders/ progress Nts.for changes. □ Check Mar for new times/meds Notes from report Lab tests ____________ IV sol. ______________ Rate ________________ Type of VAD: LIB: □All Meds available □Sign/Check med sheet T ___________________ P ___________________ R ___________________ B/P______________ Pain ____________ O 2 Sat ___________ □Rm Air □Nasal Cannula □ Meds to be given VS Accucheck ___________ Treatments ___________ ______________________ □ Focused Assessments □ Meds □ Treatments Lab results _________________ _________________ _________________ _________________ Diet ordered _____ % ______ cc ______ □Meds □Treatments □ _______ □ _______ □ _______ □Meds □Treatments □ _______ □ _______ □ _______ HS Care □ Meds □ Treatments T __________ P __________ R __________ B/P ________ Pain _______ O 2 Sat _____ □Meds given Intake _______ Output _______ NG _______ Treatments ______________ □Meds □Treatments Accucheck ___________ □ Meds □ Treatments □Report off □Charting □Sign all meds Pt. _____________________________________ Code _____________________ Age _____________ Day 2 Diagnosis ________________________________________ Surgery Date ____________________________ Activity Order _____________ Allergies _____________________ 1430 1600 1700 1800 1900 2000 2100 2200 □ Check Orders/ progress Nts.for changes. □ Check Mar for new times/meds Notes from report □All Meds available □Sign/Check med sheet T ___________________ P ___________________ R ___________________ B/P__________________ Pain ____________ □ Meds □ Treatments Lab results _________________ _________________ □Meds □Treatments □ _______ □Meds □Treatments □ _______ □ Meds □ Treatments T __________ P __________ R __________ □Meds □Treatments □ Meds □ Treatments □Report off □Charting
Transcript
Pt. _____________________________________ Code _____________________ Age _____________ Student ____________________________________________ Day 1
Diagnosis ________________________________________ Surgery ________________________________ Activity Order ___________________ Allergies ______________________________
□All Meds available□Sign/Check med sheetT ___________________P ___________________R ___________________B/P______________Pain ____________O2Sat ___________ □Rm Air □Nasal Cannula□ Meds to be given VSAccucheck ___________
Treatments _________________________________
□ Focused Assessments
□ Meds□ TreatmentsLab results_________________
_________________
_________________
_________________
Diet ordered _____
% ______ cc ______
□Meds□Treatments
□ _______
□ _______
□ _______
□Meds□Treatments
□ _______
□ _______
□ _______
HS Care
□ Meds□ Treatments T __________P __________R __________B/P ________Pain _______
O2Sat _____
□Meds givenIntake _______Output _______
NG _______
Treatments______________
□Meds□Treatments
Accucheck
___________
□ Meds
□ Treatments
□Report off□Charting□Sign all meds
Pt. _____________________________________ Code _____________________ Age _____________ Day 2Diagnosis ________________________________________ Surgery Date ____________________________ Activity Order _____________ Allergies _____________________
Solitude and Social InteractionSpecial senses exam) vision, hearing, taste smell), discomfort, sexuality, menses, vaginal drainage (lochia), breast, fundus of uterus, history of pregnancySocial skills, coping skills assets and strengths, communication content and speech pattern
Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology NANDAs
ELISA __________
CD4 ____________
VDRL__________
Thought process, alteredSensory perceptual alterationImpaired verbal communicationSexual dysfunction
Data Gathering/Diagnostic Tests Narrative Assessment Pathophysiology NANDAs
Blood alcohol
Drug levels
Pack per year:
Ineffective individual copingIneffective family copingRisk for self-mutilationNon-complianceKnowledge deficit R/T ______
Developmental SCR Developmental tasks, adjustments related to aging, parenting behaviors, experiences that impact human development, grieving processWeight (pounds/kilograms and percentile), length/height (inches & percentile), head circumference (inches & percentile)
Data Gathering/Diagnostic Tests Narrative Assessment Deficits / Nursing Interventions NANDAs
