Professional Documents
Culture Documents
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MEDICATIONS
Medication Route/ Classification, Major Side Effects Nursing Implications Evaluation/
Generic Safe Dose Time/ Action, & Effectiveness
and Trade Range/ Frequency Indication for Client
Names
Ordered
Dose
C
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Medication Route/ Classification, Major Side Effects Nursing Implications Evaluation/
Generic Safe Dose Time/ Action, & Effectiveness
and Trade Range/ Frequency Indication for Client
Names
Ordered
Dose
C
3
LAB/DIAGNOSTIC TESTS
Lab/Diag Tests Purpose of Test Date and Results Implications for abnormals
(List Normal Admission (what caused it for this patient & your
Values) Most Recent interventions for it)
WBC Determine if an infection is
3.4-10.7 k/ul present.
RBC Monitor RBC count/ to
4.0-5.4 mil/ul determine a health problem
Hgb Monitor hemoglobin in RBC/
12.0-16.0 g/dl assist in diagnosing anemia/
ck body fluid deficit
Hct Monitor volume of RBC in
38-47 blood during debilitating
illness
Platelets To check/monitor platelet
125 count
Glucose To confirm diabetic mellitus;
Fasting: 70-110mg/dL monitor blood glucose levels
Na To monitor sodium level; to
135-145 mEq/L compare Na to electrolytes
Other Labs
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X-rays, CT, MRI, Purpose of Test Date Results Implications
US
12 lead EKG, ABG,
etc
To identify bone structure
X-ray and tissue in the body. Also
detects abnormal size,
structure, and shape of bone
and body tissues.
Examination of the body
CT from many angles utilizing a
scanner analyzed by a
computer.
Non-invasive examination
MRI that uses magnet and radio
waves to produce a picture
of inside the body.
A technique that uses high-
US frequency sound waves to
echo off body organs,
creating a picture
Records the electrical
impulses of the heart by the
EKG means of electrodes and
galvanometer (ECG
machine)
1. ___________________________________________________________________________________________________________
2. ____________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________
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4. ____________________________________________________________________________________________________________
5. ___________________________________________________________________________________________________________
6. ___________________________________________________________________________________________________________
7. ____________________________________________________________________________________________________________
8. ___________________________________________________________________________________________________________
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Nursing Process
Nursing S=Supportive Data Goals/Outcomes Nursing Orders & Scientific Basis Client Responses/
Diagnose for Client Intervent for
s Nursing Centered, ions Action/Ra Evaluation
P=Client Diagnosis Stated in Include at least 5 tionale
Problems You must include: Behavioral specific interventions BE SPECIFIC!
(number Subjective Terms per problem. Asterisk Include source and
in order of Objective with (*) those interventions page number for
priority) Desired you implemented.
each intervention.
E=Pathophysiolog Outcomes
y/ (Must be specific
psychosocial and measurable)
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SYSTEM ASSESSMENT
Circle and describe appropriate responses. If abnormal, describe findings in narrative note.
Vital Signs
GENERAL
Description of physical appearance: (Describe how client looks.)
EYES Vision loss, artificial eye, glasses, contact lens, excessive tearing,
sty, exophthalmus, cataracts, sclera, ptosis, discharge
(describe)__________ other: _____________________
Color____________; Pupils: size_______, reaction PERRLA
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Vital Signs
GENERAL
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Vital Signs
GENERAL
Describe posture:
IV/ IV site(s) and type(s)____________________________
INFUSION Gauge__________
CATHETER Date inserted: __________ Site condition:
ASSESSMEN ___________________________
T
Fluids or Drips infusing: __________________________ Rate:
__________
THERAPEUTIC CPM, walker, crutches, cane, trapeze, prosthesis, wheelchair,
Or scooter, SCDs, TEDs, Heating pad, Ice pack, bed fall monitor,
ASSISTIVE therapeutic bed, wound VACs, epidural catheter, IV controller,
DEVICES PCA pump, cooling/heating blanket,
DOCUMENTATION
Date/Ti
Notes
me
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Vital Signs
GENERAL
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