Templates Ana

8/3/2019 Templates Ana

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Client Research Sheet

Student name: Anna Carmela Bencio

Client Initials:

Age:

Room:

Date:

Code Status:

Diet Order:

Allergies:

Client Diagnosis:

y

Admission Reason:

y

Past Medical History:

y


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Doctors Orders:

Intravenous Solution:Rate:Change tubing?

Site?

Foley Catheter Ins/ Outs due when?

Dressing Change? Where?How often?

Dressing change order:

Vital Signs How often?Baseline?

Chemstrips? When?Are they NIDDM or IDDM?

NG tube? What type of suction?How much did it drain last shift?

What type of drainage?

Mobility? Is this patient mobile?

One or two person transfer?Can they walk to the BR?

Do they use a cane or walker or lift?Special precautions for this type of surgery?

Other drains? Where?What type of drainage?

How much did it drain last shift?

Tube feed? What solution?What rate?Flushes? When, with what, how much?

O2 Therapy Are they on O2?How much?

What should their O2 sats be?Incentive spirometer?

Chest physio?

Pain meds? PCA? Medication:Epidural? Continuous? Single Shot? Medication?

Intermittent pain meds? What?How much?

How often?


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Diet? What type?

Have they been nauseous over the past 24c hours?

Neurovascular VitalSigns

Review the patient NVVS over the past 24 hours. Have they beennormal

MISC


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Care Plan Guide

Student Name: Anna Carmela Bencio Client Initials:

Co-Assigned Staff: Room # Age

Client Diagnosis:

Allergies: Code Status:

ASSESSMENT DATAPhysiological Variable

General Appearance/Mental Statusy

Urinary Systemy

Integumentary Systemy

Sensory Systemsy

Musculoskeletal System

y

Development Variabley

Nervous System

y

Sociological Variabley

Respiratory Systemy

Cardiovascular Systemy

Psychological Variabley


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Medical Diagnosis:

Signs and Symptoms: Complications:

Diagnostic Test (explain):

Nursing Interventions:

Medications:


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Medical Diagnosis:




Medications:


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Medical Diagnosis:




Medications:


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Medication List


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Nursing Process Care Plan

Actual/Potential/Wellness ProblemsNursing Diagnoses

Client Goals(ExpectedOutcomes) Nursing Interventions

GoalMet

GoalNotMet

Evaluation rationale for why goalmet or not met; effectiveness ofnursing interventions


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GoalMet

GoalNotMet



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GoalMet

GoalNotMet



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Go

alMet

GoalNotMet



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Go

alMet

Goal

NotMet



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Medication Research Record

Please document medication research in this format. Medication cards are still required.

DATA COLLECTION

Medication/Reason forMedication Order

Dosage/SafeDose

Action Common Side Effects Nursing Implications


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Dosage/SafeDose



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Dosage/SafeDose


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