NAME: ___________________________________ COURSE: ______________
CLINICAL DATE(S) ________________________
To be completed for EACH assigned patient.
Client’s Initials _______ Sex ___ Age ______ Marital Status __________ Religion __________
Occupation _________________________ Allergies _________________ Room # __________
Erikson’s Psychosocial Stage _____________________________________________________
Developmental Task ____________________________________________________
Physician(s) ___________________________________________________________________
List specialty ( if numerous assigned physicians)
Chief Complaint ________________________________________________________________
Primary Diagnosis ___________________________ Secondary Diagnosis _________________
Past Medical History ____________________________________________________________
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Textbook description of the client’s condition.
(Include signs/symptoms and pathophysiology)
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Signs/symptoms noted on arrival to the hospital.
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Metropolitan Community College

Diagnostic tests R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page3
Medications R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page 4&5
Other medical treatments/interventions R/T client’s condition.
Include surgical procedures (define each procedure & relate to client’s condition)
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What complications may occur, or what could go wrong?
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What interventions may prevent complications?
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Teaching
Describe the teaching that needs to be completed regarding any of the above issues while the client is still in the hospital.
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Describe the teaching that needs to be completed regarding any of the above issues related to the client’s discharge.
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Metropolitan Community College

Laboratory Values/Diagnostic Test Results
Laboratory/Diagnostic
Test
Ex: hemoglobin
Date of Test
7-27-09
Client Values n/a
6
Normal Values
Male:
Female: 12-14
Relationship/Correlation to Client
What is causing this result for this client? anemia due to GI bleed
Metropolitan Community College

Drug Name /
Classification
Therapeutic/pharm
Ex: Ibuprophen
NSAID/analgesic
Medication Information Sheet
List first the medications you will administer, then PRN medications, then other medications client will receive.
Dose, Route,
Frequency, Time of admin
800mg 3 times/day oral 0700-1300-2000
Mechanism of
Action
(how it works in the body)
Inhibits prostaglandin synthesis
Use for This
Client analgesic
Side Effects /
Interactions/toxic effects
CHF;MI;erythemia; GI hemorrhage;agranulocytosis
Do not use in CV surgery; take with milk/food; no alcohol;monitor dose do not exceed
1200mg/24h
Nursing
Considerations/ administration concerns
Metropolitan Community College

Drug Name /
Classification
Therapeutic/pharm
Dose, Route,
Frequency
Medication Information Sheet (cont’d)
Mechanism of
Action
(how it works in the body)
Use for This Client Side Effects /
Interactions/toxic effects
Nursing
Considerations/ administration concerns
Metropolitan Community College

Nursing Diagnosis
□ At which level of Maslow’s Hierarchy of Needs does this client fall on this shift?
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□ What is this client’s priority nursing diagnosis for this shift? ( Problem R/T _________AEB_________)
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□ What is the goal for this client with regards to his/her condition? (SMART Goal)
Client will:
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□ List 5 nursing interventions and rationales for this client in order to meet this goal.
Interventions Rationale
□ Did the client meet his/her goal?
(If not, explain, and describe how the interventions/goal could be revised.)
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Metropolitan Community College