Weekly Patient Preparation
Noticing:
Student: _______________________________
Dates of Care: _______
Patient Initials: _____
Age: _____
Date of Admission: _______
Marital Status: ______
Race/Ethnicity: ________
Sex: _____
Language: __________
Religion: __________________ Practicing religion: Y or N? Occupation: ______________
Admission weight: _______ Height: ________: Vital Signs: _________________________
Allergies and reaction by patient: _______________________________________
Admitting Diagnosis: _________________________________________________
Additional Diagnoses: ________________________________________________
Surgery and date if applicable: _________________________________________
Chief Complaint: Include events leading up to hospitalization and present illness. (Format should be in
Narrative and include 1. Why the patient came to the hospital in their words. 2. Pertinent History. 3.
Relevant ED work up and diagnostics. 4. State admitting diagnosis 5. Current state or plan)
Additional History of previous illnesses and surgeries (give year of illness or surgery)
Diagnosis specific nursing orders (during your time of care) Examples: meds, daily weight, I & O,
dressing change, finger stick, O2 therapy, turn patient every 2 hours, feed patient, tube feedings, PT,
ambulate patient.
Describe diagnostic and /or laboratory tests, related physiology, findings, procedure and patient care.
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NOTICING:
LAB VALUES:
Briefly explain and discuss the patient’s abnormal values correlating them with the patient’s diagnoses and
therapies (i.e. drug therapy or surgery). Include at minimum the Admit labs and Date of care. Also note trends
(up and down) and postulate why. Cite your reference for your explanation. Do not restrict yourself to Lab
tests only, include all other data such as pathology results, heart cath results, pulmonary function tests,
X rays, radiology studies, etc. etc. etc.
Test
Test
Normal Values Patient Value Patient Value
Admit
Normal
Date (Day
Date: (Day of
Before
Clinical):
Clinical)
(ER)
:
Values
Rationale
Rationale
Na
K
Cl
CO2
Glucose
BUN
Creatinine
Magnesium
Calcium
Phosphorus
RBC
WBC
Hgb
Hct
Platelets
PTT
PT/INR
Albumin
T. Protein
Bilirubin
ALT/AST
Ammonia
Troponin
BNP
Lactic Acid
HGB A1C
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Other tests results: ( Xray, CT, MRI, 2D echo, etc). Note the dates and time they were done, the
patient’s results and the test norms. Each specific hospital’s norms must be used.
XRAY:
MRI:
CT:
Ultrasound
12 Lead EKG:
ECHO:
ABG:
ph:
Co2:
PaO2:
HCO3:
Be:
SaO2:
FiO2:
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NOTICING:
Physical Assessment Guidelines Med-Surg
System
Neurological
Eyes, ears, nose, throat
Respiratory
Cardiovascular
Peripheral Vascular
GI
Musculoskeletal
Genitourinary/Reproductive
Integumentary
Psychosocial
BP: _______
Exam
MAP: _______
IV Site: __________________
Chart
Level of consciousness
Orientation: person, place, time, purpose
Short/Long Term Memory
Extremities: movement, sensory deficits
Taste, Smell, Sensation Abnormalities (Use quotes):
Visual acuity: PERRL, eyes open spontaneously
Hearing: normal conversation
Oral/Nasal mucosa: color, moisture, swallowing
precautions
Neck: ROM, lymph glands, thyroid
Respirations: rate & rhythm
Breath sounds: rales, rhonchi, wheezes
Color: lips, mucous membranes, nail beds
Cough
Sputum: color, consistency
Use of O2 Trach
Heart: rate & rhythm, dysrhythmias
Heart sounds: (S1, S2, S3, S4)
Pacemaker or AICD
Pulses: peripheral, Pedal
Neck veins: carotid bruit, JVD
Extremities: color, temperature, edema, skin texture,
Chest tubes
Capillary refill, color (discolorations), ulcerations, hair
distribution, temperature
Nail ridging, clubbing or fungal infections
Auscultate bowel sounds
Last BM
Contour: flat, round, protuberant, distention, ascites
Palpation: Tenderness
Percussion: dull, tympanic
Gait; safety precautions or equipment
Joints: ROM, contour, redness, tenderness
Muscles: symmetry, strength, tone
Fall Risk
Bladder distention (output), (FC) Dialysis
Continent, catheter, pain, lesions, etc.
Urine color, odor, sediment
Skin: color, texture, turgor, moisture, temperature
Inspect for: scars, lesions, bruising, cyanosis, pallor,
erythema
Wounds, Drains, and Location(s).
Braden Scale
Responds to care
Behavior congruent with diagnosis
Concerns
Pulse: ______
Resp Rate: _______
Temp: ______ Pain: ______
IV Fluids: ________________________@ _____cc/hr
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Interpreting:
A. Patient’s Diagnosis (Highlight any elements that your patient has)
1. Define the admitting diagnosis:
2. Etiology and Incidence:
3. Pathophysiology (In narrative format with patient specific data, at least three paragraphs or a detailed concept
map with patient specific data or a pathophysiology flowchart/outline with Patient specific data):
4. ALL Expected Diagnostic tests and findings for the Pathophysiology you focused on (highlight any that your
patient received include values):
5. ALL Expected Clinical manifestations and Complications (highlight any that your patient presented with):
6. ALL Risk Factors for the Primary Diagnosis (highlight any that your patient has):
7. Anticipated Collaborative care:
8. Nursing Management: (List potential nursing interventions)
B. Describe the acute surgical procedure (if applicable), purpose and patient care (before, during and after the
procedure).
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After your shift report and initial assessment, identify the nursing problems (diagnoses) that your patient has. Using the provided form, develop a nursing care
plan (goal/objectives, interventions, evaluation) for the highest priority diagnosis.
RESPONDING:
IV.
Nursing Care Plan
Pt Initials: _____
NURSING DIAGNOSIS
(Highest Priority of Care on the day you cared
for the patient, not their admitting diagnosis
priority)
NANDA
Related to: can be more than one cause (Cannot
be a medical diagnosis as the primary related to
factor)
Room Number: _____
OBJECTIVES:
Objective (can be more then 1):
patient centered, specific &
measurable, achievable within a
reasonable time frame. Your
objectives must maintain or improve
at least one of your manifestations.
Dates of Care: ______
NURSING INTERVENTIONS
(Show a clear plan of how you will achieve your objectives, do
not just list interventions)
Independent (4-5)
Dependent (1-2)
As Evidenced By:
Subjective Manifestations (Evidence)
Collaborative (1-2)
Objective Manifestations
(Evidence)
Pt. education (1)
Focus on the nursing diagnosis &
“related to” (causes)
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Patient Teaching: Provide one (Knowledge Deficit or Readiness) NANDA, along with objectives and a teaching plan (interventions). This should be realistic
and incorporate a strategy to evaluate that knowledge transfer has occurred (ie. teach back, closed loop communication, demonstration, etc)
NANDA (Write Full Statement):
Objective(s):
Plan:
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Reflection
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References
(APA Format)
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CALIFORNIA STATE UNIVERSITY, LOS ANGELES
Patricia A Chin School of Nursing
Student Assignment Worksheet
(Optional for Data Collection in Hospital)
Student Name: ___________________________
Patient’s Initial ____________
Age: _______ Sex: __________
Room #: ___ Adm. Date: ____
Adm. Diagnosis: __________
________________________
Surgery/Date: _____________
________________________
________________________
Allergy: _________________
________________________
Code Status: _____________
Routine Medications:
Date: _____________
Other Treatments:
O2 therapy: _______________
Incentive spirometer: ________
Resp. therapy:
Physical therapy:
CPM:
Renal dialysis:
RN: _____________________
CNA: ___________________
Other:
Other:
Activity: BR BSC BRP
Assist: Chair Amb ad lib
IV Site:
ABG:
Diet:
IV Solution:
Lab and diagnostic tests/results
(for the date of care):
Fluid Restriction:
Rate:
N/G or G/T feeding:
PRN Medications:
I&O:
TPR:
BP:
Pain Assessment:
O2 Sat:
% on
PCA:
EKG:
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