NURSING HISTORY FIRST DAY

Patient Initials: _______ Room No: ______Sex_______ Age________Weight: ______ Date__________Allergies_____________________________________Working Medical Diagnosis/ Chief of Complaint________________________ Diet Ordered: _________________Restrictions: ___________________________Type of Isolation:________________________________DNR Status or Advance Directives________________________________________________________ Scheduled Procedures or Test: ________________________________Reason for Procedure or Test: ________________________________________________

AMERICAN CAREER COLLEGE, VOCATIONAL NURSING PROGRAM

1. Source of Information: Primary or Secondary (Specify)_______________2. Chief Concern (Reason for Admission): ___________________________3. History of Present Illness (a chronological description of why the client seeks care; include the onset and severity of signs and symptoms, treatments used and corresponding effectiveness, and clients understanding of the illness): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Past Health History and Current Health Statusa. Childhood Illnesses (a list of previous chronic and communicable diseases experienced as a child): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________b. Past Medical Illnesses (a list of the clients past diseases include the year it was diagnosed):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ c. Surgical History (a list of the clients previous operations and the year the surgery was done): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Family History (a list of the diseases and or cause of death among the clients immediate family) a. Mother :________________________________________________ b. Father: _________________________________________________c. Siblings: ________________________________________________d. Grandparents: ___________________________________________e. Partner: ________________________________________________f. Children: _______________________________________________

6. Social History: a. Educational Status (Highest educational level obtained): _______________________________________________________b. Support System (Presence and type) : _______________________________________________________c. Concerns about Living Conditions (fire hazards, safety hazards, fall hazard etc):_____________________________________________________________________________________________________________________________________________________________________ d. Ability to perform activities of daily living (identify if the client is independent, partially dependent for assistance, or totally dependent for assistance) Bathing: ____________________________________________ Grooming : __________________________________________ Walking: ____________________________________________ Climbing up and down the stairs: _________________________ Cooking: _____________________________________________ Buying medications: ___________________________________ Taking medications: ___________________________________ Buying groceries: ______________________________________ Cleaning: ____________________________________________ Special medical treatments and treatments at home:_______________________________________________e. Assistive devices (type and reason for use)______________________________________________________________________________________________________________Spiritual health (spiritual concerns or requests):______________________________________________________________________________________________________________

7. Health Promotion Behaviorsa. Recreational Drug use (presence, type, duration): ____________________________________________________________________________________________________________________b. Smoking (how many sticks/ packs per day; how many total years as a smoker:)__________________________________________________________ c. Alcohol (type, ounces per day or week:)__________________________________________________________d. Exercise or activity (type, frequency and duration:)__________________________________________________________e. Diet (clients typical die description:) ____________________________________________________________________________________________________________________f. Sun Exposure (presence, duration)__________________________________________________________g. Sexual Practice and Contraceptive Use ______________________________________________________ h. Stress and Coping Mechanisms (sources of stress, the clients way of coping and the effectiveness of these coping mechanisms )________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ACTIVE MEDICAL DIAGNOSES, CURRENT MEDICATIONS AND DIAGNOSTIC TESTSFIRST DAY

Other Active Medical or Surgical Diagnoses Patients Medications (Name, Dose, Frequency Route); Please place medication with the corresponding medical diagnoses Diagnostic Tests(Only use values that are abnormal)

(This section does not need to correspond per row with the diagnostic section)Name of Test Reason for Test Normal Range Patients Values (indicate patients actual values and if high or low) Significance(explain possible reasons for the obtained values)

1st DAY

DOCTORS ORDERS Date OrderedOrdersRationale

ASSIGNED CASE2nd DAY

Chief Complaint or Priority Medical Diagnosis: ______________________________________________Definition

Pathophysiology

Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Chief Complaint or Priority Medical Diagnosis: ______________________________________________

Definition

Pathophysiology

Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Chief Complaint or Priority Medical Diagnosis: ______________________________________________Definition

Pathophysiology

Signs, Symptoms and Abnormal Diagnostic Findings Present in Your Patient

Daily Plan of Care Per Day with Progress Notes & PE

Identified Nursing Diagnosis (3 part nursing diagnosis statement):____________________________________________________________________________Long Term Goals: Weeks to Months (Please ensure that it is a patient centered goal that is specific, measurable, attainable, realistic and time bound. Please ensure that this goal addresses the main problem) Evaluation(Please check of the appropriate status of your client) As Evidenced by (Please put supporting signs and symptoms to justify the identified status of your patient)

( ) Goal Met ( ) Goal Partially ( ) Goal Unmet

Short Term Goal: Hours to days(Please ensure that it is a patient centered goal that is specific, measurable, attainable, realistic and time bound) Evaluation(Please check of the appropriate status of your client) As Evidenced by (Please put supporting signs and symptoms to justify the identified status of your patient)

( ) Goal Met ( ) Goal Partially ( ) Goal Unmet

( ) Goal Met ( ) Goal Partially ( ) Goal Unmet

Planned Interventions Classification Interventions (Please put enough interventions to solve or reverse the problem) Implementation Status

Assessment(Indicate what you will be monitoring) ( ) Completed( ) Ongoing( ) Not Done

Rationale

Implementation(Indicate what you will be DOING for the patient) 1. ( ) Completed( ) Ongoing( ) Not Done

Rationale

2. ( ) Completed( ) Ongoing( ) Not Done

Rationale

3( ) Completed( ) Ongoing( ) Not Done

Rationale

Health Teaching(indicate the topic you which to teach your client )( ) Completed( ) Ongoing( ) Not Done

Rationale

Evaluation(Indicate what will be monitored after the interventions has been done) ( ) Completed( ) Ongoing( ) Not Done

DRUG STUDY Before Medication Administration

(Include all prescribed medications, over the counter medications and supplemental/ nutritional or alternative medications the patient is taking) Medications Name (Brand and Generic Name, Classification)Frequency, Route, DoseSafe Dose Range

Within Range? Indication Mechanism of Action Side EffectsContraindicationsTop 3 Nursing Interventions(Include assessment, monitoring, special diets, restrictions and hold orders)

Yes/No

Yes/No

Yes/No

Yes/No

Medications Name (Brand and Generic Name, Classification)Frequency, Route, DoseSafe Dose Range

Within Range? Indication Mechanism of Action Side EffectsContraindicationsTop 3 Nursing Interventions(Include assessment, monitoring, special diets, restrictions and hold orders)

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

AT THE END OF THE ROTATION Last Day

Nursing Diagnoses: 3 Priority Actual Nursing Diagnosis 1 Risk Nursing Diagnosis 1 Concept Map to Summarize all Plan of Care Done for the patient

Prioritization Justification of Prioritization Type of Diagnosis 3 Part Nursing Diagnosis (Diagnostic Label, Etiology and Supporting Cues)

Actual

Actual

Actual

Risk

Health Teaching

Concept Map

Per Day

Sources: Tile of the Book/ WebsiteAuthorYear of PublicationPageEdition

CLINICAL INSTRUCTOR INSTRUCTIONS How to use these forms:

These packet contains the following documents: Assessment Documents: Physical Assessment Nursing History Active Medical Diagnoses, Current Medications and Diagnostic Tests and Laboratories Doctors Orders Assigned Case or Chief Complaint Daily Plan of Care Progress Notes Drug Studies Synthesis (Concept Map) Citation of Sources

DESCRIPTION AND INSTRUCTIONS Assessment Documents: Physical Assessment: Our current assessment is based on Orem s Self-Care Deficit. The forms are progressively reduced in content from Term 1 to Term 4 to assist the student in learning how to document the normal and abnormal findings. Student must perform a physical assessment for their assigned patient on the first hour per day. Daily physical assessments must be submitted at the end of the shift to the instructor. It is recommended that initial assessments be done with the instructor for the clients safety.

Nursing History: This is a short version of the nursing history. It includes the chief complaint, history of present illness, past medical illness, social history, environmental history, family history and spiritual history. Student must obtain at least one complete history for the assigned patient. The client is only interviewed upon being assigned to the student.

Active Medical Diagnoses, Current Medications and Diagnostic Tests and Laboratories: This is equivalent to the clients review of records. This is to be completed on the first day also. Please countersign the page and validate that the data represents the actual clients information. Please do not discard the original records for comparison purposes. The rationale and relevance of diagnostic tests and laboratories may be assigned to the student as homework in preparation for the next clinical day. Doctors Orders: This is to be obtained on the first day also. The rationale for the doctors orders are to be researched by the student as homework.

Assigned Case or Chief Complaint: This section refers to the medical condition or diagnoses that you assigned to the student. This can be the basis of their plan of care. Please ensure that assigned cases are relevant to Term Objectives. For example Term 2 students may be given clients who have cardiovascular illnesses while Term 3 students can be given Diabetic clients after they have discussed Diabetis Mellitus in lecture). Please coordinate with the theory instructor as to what system they have completed. The pathophysiology and definition are to be researched by the students as homework.

Daily Plan of Care: This is to be completed ideally before any day of implementation. When approving nursing diagnoses, please prioritize actual nursing diagnoses over risk nursing diagnoses. Please correlate the nursing diagnoses with the chief complaint or assigned case. The Plan of Care was formulated to reflect the Nursing Process.

Progress Notes: Please document the interventions provided to the client on that day. We are discouraging duplicating the physical assessment findings on the progress note. The progress note should reflect routine interventions done for the patient (range of motion, assisting with feeding etc), abnormal responses, the interventions that were implemented and the clients response to these interventions.

Drug Studies: Please do not allow students to pass medications unless an 80% or higher score has been obtained in the drug calculation test. Please validate the students understanding of the medications and its relationship to the clients history, medical diagnoses and diagnostic tests. A student who is unable to discuss the medications of her client should not be allowed to pass medications. The recommendation is for the drug study to be completed for ALL the assigned patients medications (not just the ones that the students are currently administering).

Synthesis (Concept Map): On their last day, the students are to summarize their client experience. A concept map is required to show prioritization among medical diagnoses, nursing diagnoses, interventions and diagnostic tests. The purpose of the concept map is to show the relationship of all of the clients risk factors, medical illness, nursing diagnoses, diagnostic tests and nursing interventions.

Citation of Sources: These papers are considered scientific papers. Any information obtained from literature, websites, reference materials etc must be properly documented. Please reinforce that we do not allow plagiarism.