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Student Name:: Clinical Week #: Clinical Instructor
Student Name:: Clinical Week #: Clinical Instructor
doc
Client Initials: Age: Date of Admission: Hospital day # Date: Medical Diagnosis: Surgical Diagnosis: Current Vital Signs: 1) BP _______ P _______ RR ________ T _______ 2) BP _______ P _______ RR ________ T _______
PATHOPHYSIOLOGY: Briefly describe the following utilizing one of your clients medical diagnoses Pathophysiology
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Currently relevant orders, prescribed medications and therapies within past 24 hours (PLEASE NUMBER) 1. Diet: 2. Vital signs 3. Activity: 4. Wound care: 5. IV fluid: 6. Diagnostic procedures/ labs:
WRITTEN rationales for each order, prescribed medication and therapies (PLEASE NUMBER TO CORRESPOND TO LEFT COLUMN) 1. Rationale: 2. Rationale: 3. Rationale: 4. Rationale: 5. Rationale: 6. Rationale
7. Therapies
7. Rationale:
LAB RESULTS:
BRIEF DESCRIPTION OF SURGICAL OR INTERVENTIONAL PROCEDURE Name of procedure: ____________________ Description of procedure: Surgery or Intervention date ________ POD # _______
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RATIONALES FOR PRESCRIBED MEDICATIONS: Routine meds (scheduled) and any PRN given within past 24 hours (add pages as needed) DIRECTIONS: add pages as needed to include all you clients current prescribed meds and PRNs MEDICATION (generic and Trade name, drug classification Dose, route, frequency MECHANISM OF ACTION EFFECT ON CLIENT WHY CLIENT IS TAKING THIS MED NURSING CONCIDERATIONS
Presenting Symptoms
Nursing Diagnosis
Nursing Diagnosis
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Data
Reason for Seeking Health Care (Medical Diagnosis) Data Expected Outcome
Expected Outcome
Risk Factors
Interventions
Data
Interventions
Evaluation
Expected Outcome
Expected Outcome
Evaluation
Interventions
Interventions
Evaluation
Evaluation
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