CAT Date:________ Code Adv. Dir.

Allergies Day One: Neuro Day Two: Day One: Cardiac Day Two: Day One: Resp. Day Two: Day One: GI Day Two: Day One: GU/GYN Day Two: Day One: Mus/Skel Day Two: Day One: Skin

PATIENT INITIALS__________ Student______________________ PMH / SH Admit Date/ Diagnosis

Day Two: Day One: Pain Day Two: Day One: Psych/So c Day Two:

Day One: ADLs Day Two: IV Site Day One: Day Two:

Vital Signs Baseline Data Time: Temperature oC Route Acute care setting data Time: Temperature oC Route Time: Temperature oC Route Time: Temperature oC Route Pulse (site) Pulse (site) Pulse (site) Pulse (site)

Admission height: BP BP BP BP SPO2 Via: SPO2 Via: SPO2 Via: SPO2 Via:

Weight: RR l/min RR l/min RR l/min RR l/min Pain Scale Pain Scale Pain Scale Pain Scale

Lab Study WBC HCT HGB PLTS

Normal 4.5-11,000 38-49 % 12-18 % 150-450 Tho/uL

Date

Date

Date

Date

Date

GLUCOSE NA K CL CO2 BUN CR CA MG Mg - MCH PHOS. ALBUMIN PH PO2 PCO2 LACTATE HCO3 PT PTT INR CK CK MB TROPONIN BNP Lab Study AST ALT HgbA1c UA

60-110 mg/dL 135-145 mEq/L 3.5-5.0 mEq/L 97-107 mEq/L 25-26 mmol/L 5-20 mg/dL 0.5-1.1 mg/dL 8.2-10.2 mg/dL 1.6-2.6 mg/dL 5-8 mg/dL 2.5-4.5 mg/dL 3.4-4.8 g/dL 7.35-7.45 85-100mmHg 35-45 mmHg 0.4-0.8 mmol/L 17-24 mEq/L 10-13 secs 30-45 secs 2.0-3.0 therapeutic 26-174 U/L < 6% CK <0.3 ng/ml < 100 Normal Date Date Date Date Date

<7.0 in DM

LAB VALUE ANALYSIS

Concerns: What do you think is causing the abnormal value? Do not fill in every cause, just the ones pertinent to your client. How do the lab values relate to your physical assessment/diagnoses and/or the medical diagnoses? What complications do you anticipate and did you assess for those symptoms? Are there any labs you want to discuss with the provider or request an order for? Why?

Define Primary Health Problem (Medical Diagnosis)

Primary Medical/Admitting Diagnosis: Related Surgical Procedure (Date): Pathophysiology (how normal anatomy and physiology is altered by the patients disease/problem):

Etiology (cause of the disease):

Expected Signs and Symptoms (circle those exhibited by your patient):

Typical Nursing Management (include the range of treatment options for this problem and circle those that apply to your patient):

Typical Medical Management (include the range of treatment options for this problem and circle those that apply to your patient):

Textbook References and resources (include title and page number):

Scheduled Medications
Name (Generic and Brand) Classification (therapeutic and pharmacological) Current Medication Order (dose, route, frequency) Recommended Route and Dosage & Max Daily dose Indication: Why is this patient receiving this medication? Action & Therapeutic Effects Pharmacokinetics Metabolism and Excretion onset, peak, duration (insulin and IV meds) Half life Reversal agent (if applicable) Adverse/Side Effects (major/life threatening in bold type and most commonly occurring in blue type) Key Nursing Implications: *Administration parameters, food/drug interactions *Implementation and Assessment * Education * Relevant lab data

PRN medications
Name (Generic and Brand) Classification (therapeutic and pharmacological) Current Medication Order (dose, route, frequency) Recommended Route and Dosage & Max Daily dose Indication: Why is this patient receiving this medication? Action & Therapeutic Effects Pharmacokinetics Metabolism and Excretion onset, peak, duration (insulin and IV meds) Half life Reversal agent (if applicable) Adverse/Side Effects (major/life threatening in bold type and most commonly occurring in blue type) Key Nursing Implications: *Administration parameters, food/drug interactions *Implementation and Assessment * Education * Relevant lab data

NURSING DIAGNOSIS: GOAL (long term goal): OUTCOME (short term goal):

NURSING INTERVENTIONS Assess:

PATIENT RESPONSES

Monitor:

Action:

Administer:

Collaborate:

Educate:

IMPRESSION:

NURSING DIAGNOSIS:

GOAL (long term goal): OUTCOME (short term goal):

NURSING INTERVENTIONS Assess:

PATIENT RESPONSES

Monitor:

Action:

Administer:

Collaborate:

Educate:

IMPRESSION:

NURSING DIAGNOSIS: GOAL (long term goal):

OUTCOME (short term goal):

NURSING INTERVENTIONS Assess:

PATIENT RESPONSES

Monitor:

Action:

Administer:

Collaborate:

Educate:

IMPRESSION:

NURSING DIAGNOSIS: GOAL (long term goal): OUTCOME (short term goal):

NURSING INTERVENTIONS Assess:

PATIENT RESPONSES

Monitor:

Action:

Administer:

Collaborate:

Educate:

IMPRESSION: