Patient Information (1) Patient Initials: RC Age & Gender: 18 Height/Weight: Code

Patient Information

(1)

Patient Initials: RC

Age & Gender: 18

Height/Weight:

Code Status:

Parents or Guardian:

Patient Information

(1)

Patient Initials: RC

Age & Gender: 18

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)