8/3/2019 Templates Ana
1/16
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
8/3/2019 Templates Ana
2/16
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?
8/3/2019 Templates Ana
3/16
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
8/3/2019 Templates Ana
4/16
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
8/3/2019 Templates Ana
5/16
Medical Diagnosis:
Signs and Symptoms: Complications:
Diagnostic Test (explain):
Nursing Interventions:
Medications:
8/3/2019 Templates Ana
6/16
Medical Diagnosis:
Signs and Symptoms: Complications:
Diagnostic Test (explain):
Nursing Interventions:
Medications:
8/3/2019 Templates Ana
7/16
Medical Diagnosis:
Signs and Symptoms: Complications:
Diagnostic Test (explain):
Nursing Interventions:
Medications:
8/3/2019 Templates Ana
8/16
Medication List
8/3/2019 Templates Ana
9/16
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
8/3/2019 Templates Ana
10/16
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
8/3/2019 Templates Ana
11/16
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
8/3/2019 Templates Ana
12/16
Nursing Process Care Plan
Actual/Potential/Wellness ProblemsNursing Diagnoses
Client Goals(ExpectedOutcomes) Nursing Interventions
Go
alMet
GoalNotMet
Evaluation rationale for why goalmet or not met; effectiveness ofnursing interventions
8/3/2019 Templates Ana
13/16
Nursing Process Care Plan
Actual/Potential/Wellness ProblemsNursing Diagnoses
Client Goals(ExpectedOutcomes) Nursing Interventions
Go
alMet
Goal
NotMet
Evaluation rationale for why goalmet or not met; effectiveness ofnursing interventions
8/3/2019 Templates Ana
14/16
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
8/3/2019 Templates Ana
15/16
Medication/Reason forMedication Order
Dosage/SafeDose
Action Common Side Effects Nursing Implications
8/3/2019 Templates Ana
16/16
Medication/Reason forMedication Order
Dosage/SafeDose
Action Common Side Effects Nursing Implications
Top Related