Oxygen/ Admit Sunday Monday Tuesday Rationale for Abnormalities Impact on Nursing Care

Ventilatory
Support
Mode
FiO2
Rate
TV/MV
PS
Peep/CPAP
ABGs
pH
PO2
PCO2
HCO3
O2 sat
BE
Na
K
CO2
Cl
BUN/Cr
Glucose
Calcium
Magnesium
Phosphorus
CKMB/
Troponin
WBC
Hgb/Hct
Platelet

Cultures
Blood
Sputum
Wound
Invasive Line
Urine

TAPE RHYTHM STRIP AND ANALYSIS TO BACK

 Patient Summary / Worksheet Student __________________________________________________
Client Initials: ____________ Room # __________ Age __________ G&D Stage__________ Diagnosis _____________________________
Surgery _____________________________ Allergies: ______________________________________
Brief Description of pathology/surgical procedure/Concept Map

High Risk Crisis Events and Actions:

Medications:
Medication Drug Class Dosage Route Adm. Rationale for Medication Nursing Implications Critical Lab/
Trade/Generic Name Time Drug Level
 PROBLEM LIST
Patient Initials __________ Unit __________ Student _________________________________________
Room Number __________ Date ____________________________________________

#1 Problem (NANDA Diagnosis):

Goal (NOC):
Interventions (NIC) Assessment Data: Day 1 Assessment Data: Day 2
________________________________

Evaluation / Revisions

#2 Problem (NANDA):
Goal (NOC):
Interventions (NIC) Assessment Data: Day 1 Assessment Data: Day 2
_________________________________

Evaluation / Revisions
#3 Problem (NANDA):
Goal (NOC):
Interventions (NIC) Assessment Data: Day 1 Assessment Data: Day 2
________________________________

Evaluation / Revisions

Addition Problems Teaching Needs