Student: Date/Week: Goals for Week: Risk Factors for Disease Diagnostic Test Results Lab Data

Test Value Result Range

Care Plan
Presenting Signs and Symptoms on Admission

Room:

Age:

Sex:

Admit Dx/ (Date of Surgeries)

Clinical Course of Illness Since Hospitalized

.

Allergies:

Pathophysiology

Diet:
Activity: Treatment Schedule

Wt: Admit Kg Present ____ Kg

Pertinent Hx (Social, Personal, Economic)

Biological Hx (Previous Illness, Drugs, Surgery)

Important Goals for Patient Care Comments: Comments:

Current Medications Allergies: __________

Medication Dose Route Timing

Comments:

Vital Signs
HR BP RR Temp Pain O2Stat Other: Glucose

Comments:
IVs Type CCs / Hr

Patient Initials:

Admit Date:

Nursing Process

Nursing Diagnosis

Outcomes

Intervention & Rationale

Elevation and Modification

Discharge Planning