METROPOLITAN COMMUNITY COLLEGE
RN Prelab/Critical Thinking Tool
To be completed for EACH assigned patient.
STUDENT NAME ________________________________Clinical Date _________________________________
Client’s Initials __________ Room ________ Code Status _______________ Date of Code Status_____________
Sex __________ Age _________ Marital Status __________________ Living Situation _____________________
Occupation ________________ Spiritual Affiliation ___________________________________________________
Maslow Hierarchy____________________________________ Erikson Stage____________________________
Primary Physician ______________________________________________________________________________
Specialty Physician(s) (list Physician/Specialty) ______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Chief Complaint: _______________________________________________________________________________
Primary Diagnosis: _____________________________________________________________________________
Secondary Diagnosis (if any): _____________________________________________________________________
ALLERGIES : _________________________________________________________________________________
Social
History:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Past Medical History:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Past Surgical History:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Why is your patient in the ICU/CCU/HVI/PINS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
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Pathophysiology: of the primary medical condition that has caused the patient to be admitted or transferred to
the ICU/CCU/HVI Unit:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
2
Diagnostic tests (CXR, CT, 12 Lead EKG, Echo, Etc.) completed on your patient:
Name /Type of Test
Revised 06/04/2015
Date of Test
Findings/Results/Impression
RN Med/Surg/ICU
3
Laboratory Values/Diagnostic Test Results
Laboratory/Diagnostic
Test
Date of Test
Normal Values
Client Values
Relate this value to your
patients condition (be
specific)
What is causing this result
for this client?
Make additional copies
Revised 06/04/2015
RN Med/Surg/ICU
4
Medication Information Sheet
ALL MEDS MUST BE LISTED HERE--List first the scheduled
Drug Name /
Classifications
----------------------
Dose, Route,
Frequency and
scheduled times
Action
-----------------------
SCHEDULED
medications and then PRN medications
Use for This Client
MEDICATIONS
.
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RN Med/Surg/ICU
5
Side Effects /
Interactions
Nursing
Considerations
(3)
administration concerns
(3)
-----------------------
----------------------
Drug Name /
Classification
Dose, Route,
Frequency
Medication Information Sheet (cont’d)
Action
Use for This Client
Side Effects /
Interactions
Nursing
Considerations
administration concerns
PRN
MEDICATIONS
------------------------
------------------------
Make additional copies if needed
Revised 06/04/2015
RN Med/Surg/ICU
6
------------------------
------------------------
IV MEDICATION SHEET
Primary Maintenance IV fluids currently running and rate: 1)_________________ 2) ___________________
Example: 1) Dextrose 5% and 45% Normal Saline (D51/2 NS) @ 100ml/hr
Name of
Medication and
dose
Amount and
Type of Diluents
(list how medication
needs to be
reconstituted or
diluted)
Rate of administration
(How fast will you give it?)
2) Normal Saline @ 10ml/hr (TKO)
How is this IV
Medication to be
given to patient?
(IV Push, IV drip, IV
Piggyback [Secondary])
Make additional Copies if Needed
Revised 06/04/2015
RN Med/Surg/ICU
7
Is this IV Medication
compatible with your
Primary Maintenance
IV Fluids?
Y/N
What IV medications
this patient is getting
that is NOT compatible
with this IV
Medication?
(list each # from above)
(list these IV meds in this box)
Pre-Clinical Nursing Diagnosis
□ List 3 planned priority nursing diagnosis for this patient: (Use NANDA DX______R/T____________AEB_____________)
1.__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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RN Med/Surg/ICU
8
Client Assessment
To be completed on clinical day.
Clinical Date: ________ Diagnosis: _________________________ Initials______ Age_______
General Information: (Circle or fill in)
Diet:
NPO:
Vital Signs:
Temp:
Pulse:
BP:
Respirations:
SaO2:
Pain: score:
Location:
Description:
Intervention:
Recheck score:
Time:_______
Vital Signs:
Pulse:
BP:
Respirations:
SaO2:
Pain: score:
Location:
Description:
Intervention:
Recheck score:
Time:_______
Enteral type:
Parental Type:
Vital Signs:
Temp:
Pulse:
BP:
Respirations:
SaO2:
Pain: score:
Location:
Description:
Intervention:
Recheck score:
Time:________
Rate:
Rate:
Vital Signs:
Pulse:
BP:
Respirations:
SaO2:
Pain: score:
Location:
Description:
Intervention:
Recheck score:
Time: _______
Additional Comments:
Activity:
ADL: Oral Care:________________ Hygiene:____________ Skin Care:___________
Treatments
Oxygen Therapy:
Type:
# of liters or FiO2%:
Treatments: (circle all that apply)
Tubes & Drains:
SCD’s
Ventilator Settings:
Tidal Volume: __________
Heating blanket
Chest Tube(s) # ________________
Location(s) ___________________
Drains # _______________________
Location(s) ___________________
Location(s) ___________________
Location(s) ___________________
Wound Vac Setting ______________
Location(s)____________________
# of Sponges __________________
Rectal Tube ____________________
Urinary Catheter ________________
Mode: __________ Rate ________
PEEP ________ PS ___________
FiO2% ____________________
ET size ________ (or) Trach _______
Placement at lip ____ Right Mid Left
Bi-Pap/CPAP:
Settings:
FiO2:
Continuous
NOC
Capnography
PRN
End Tidal CO2 _____ _____
Revised 06/04/2015
Plexi pulse
Cooling Blanket
C&DB
TEDS
HOB >30
IS Level:______
Turn q 2 and PRN
(note time and position)
Other ___________________
Other ___________________
Ancillary Services: (yes/no)
PT/OT ________________
Speech ________________
Dietary ________________
Social Svcs _____________
RT____________________
Other _________________
Nasogastric (NG) or Oral Gastric OG)
(Circle type) : Continuous Suction
Low Intermittent Suction Clamped
Other ______ Position: R L mid
Feeding Tube Type: (Circle type):
OG Nasal (Dobhoff) J-Tube
G-Tube
Output Characteristics
______________________________
RN Med/Surg/ICU
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Blood Sugars/
Interventions
IV Site
Hourly
urine
output
Intake Time:
Output Time:
8_____
9_____
10_____
11_____
12_____
13_____
14_____
15_____
16_____
17_____
18_____
19_____
20_____
21_____
#1
Location:_________
Fluid:_______
Rate:________
8_____
9_____
10_____
11_____
12_____
13_____
14_____
15_____
16_____
17_____
18_____
19_____
20_____
21_____
Po____
IV1_____
IV2_____
IV3_____
IV4_____
IV5_____
IV6_____
PB______TF______
Other____________
____
Void____
Foley____
CT______
Rectal___
Drain1___
Drain2___
Drain3___
Other_____________
#2
Location:__________
Fluid:____________
Rate:_____________
#3
Location:__________
Fluid:___________
Rate:___________
*Others list in
comment section
Total
Output:
Total Intake:
Telemetry Rhythm:
Time_____:
Time_____:
Time_____:
Time____:
Additional Comments/Telemetry Events:
Psychosocial Assessment
Time:
Time:
Time:
Time:
Affect:
Affect:
Affect:
Affect:
Behavior:
Behavior:
Behavior:
Behavior:
Additional Comments:
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RN Med/Surg/ICU
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Time:
Time:
Time:
Time:
Neurological Assessment
Neurological Assessment
Neurological Assessment
Neurological Assessment
Oriented to: Person Place
Oriented to: Person Place
Oriented to: Person Place
Oriented to: Person Place
Time Event
Time Event
Time Event
Time Event
Disoriented to: ___________
Disoriented to: ___________
Disoriented to: ___________
Disoriented to: ___________
Pupil Size: R 1 2 3 4 5
Pupil Size: R 1 2 3 4 5
Pupil Size: R 1 2 3 4 5
Pupil Size: R 1 2 3 4 5
L12345
L12345
L12345
L12345
Response to Light:
R Sluggish Brisk Fixed
Response to Light:
R Sluggish Brisk Fixed
Response to Light:
R Sluggish Brisk Fixed
Response to Light:
R Sluggish Brisk Fixed
L Sluggish Brisk Fixed
L Sluggish Brisk Fixed
L Sluggish Brisk Fixed
L Sluggish Brisk Fixed
Glascow Coma Scale:______
Glascow Coma Scale:______
Glascow Coma Scale:______
Glascow Coma Scale:______
RASS Score:________
RASS Score:________
RASS Score:________
RASS Score:________
Additional Comments:
Additional Comments:
Additional Comments:
Additional Comments:
Musculoskeletal Assessment
Musculoskeletal Assessment
Musculoskeletal Assessment
Musculoskeletal Assessment
History of Falls: Yes No
ROM: Active Passive
ROM: Active Passive
ROM: Active Passive
ROM: Active Passive
Strength: Strong Weak UTA
Strength: Strong Weak UTA
Strength: Strong Weak UTA
Strength: Strong Weak UTA
Hand Grasps:
Hand Grasps:
Hand Grasps:
When was last:
Hand Grasps:
L: Strong Weak None
L: Strong Weak None
L: Strong Weak None
R: Strong Weak None
R: Strong Weak None
R: Strong Weak None
L: Strong Weak None
R: Strong Weak None
LegMovement:
L: Strong Weak None
LegMovement:
LegMovement:
LegMovement:
L: Strong Weak None
L: Strong Weak None
R: Strong Weak None
R: Strong Weak None
R: Strong Weak None
Fall Risk Score: _______
L: Strong Weak None
R: Strong Weak None
Additional Comments:
Additional Comments:
Additional Comments:
Additional Comments:
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RN Med/Surg/ICU
11
Cardiac Assessment
Cardiac Assessment
Cardiac Assessment
Cardiac Assessment
Rhythm: Regular Irregular
Rhythm:Regular Irregular
Rhythm:Regular Irregular
Rhythm: Regular Irregular
Murmur: Yes No
Murmur: Yes No
Murmur: Yes No
Murmur: Yes No
If yes Where Heard:______
If yes Where Heard:______
If yes Where Heard:______
If yes Where Heard:______
Bruit: Yes No
Bruit: Yes No
Bruit: Yes No
Bruit: Yes No
Dialysis bruit/thrill: Yes No
Dialysis bruit/thrill: Yes No
Dialysis bruit/thrill: Yes No
Dialysis bruit/thrill: Yes No
Capillary Refill:
LUE: <2 sec
RUE: <2 sec
LLE: <2 sec
RLE: <2 sec
Capillary Refill:
LUE: <2 sec <3 sec
RUE: <2 sec <3 sec
LLE: <2 sec <3 sec
RLE: <2 sec <3 sec
Capillary Refill:
LUE: <2 sec <3 sec
RUE: <2 sec <3 sec
LLE: <2 sec <3 sec
RLE: <2 sec <3 sec
Capillary Refill:
LUE: <2 sec <3 sec
RUE: <2 sec <3 sec
LLE: <2 sec <3 sec
RLE: <2 sec <3 sec
<3 sec
<3 sec
<3 sec
<3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>3 sec
Radial Pulse:
L: Strong Weak Dopple Absent
R: Strong Weak Dopple Absent
Radial Pulse:
L: Strong Weak Dopple Absent
R: Strong Weak Dopple Absent
Radial Pulse:
L: Strong Weak Dopple Absent
R: Strong Weak Dopple Absent
Radial Pulse:
L: Strong Weak Dopple Absent
R: Strong Weak Dopple Absent
Pedal Pulse:
left: Strong Weak Dopple Absent
right: Strong Weak Dopple Absent
Pedal Pulse:
L: Strong Weak Doppler Absent
R: Strong Weak Doppler Absent
Pedal Pulse:
L: Strong Weak Doppler Absent
R: Strong Weak Doppler Absent
Pedal Pulse:
L: Strong Weak Dopple Absent
R: Strong Weak Dopple Absent
Edema: Present Absent Weeping
LUE: 1+ 2+ 3+ 4+ Pit Non-Pit
RUE: 1+ 2+ 3+ 4+ Pit Non-Pit
LLE: 1+ 2+ 3+ 4+ Pit Non-Pit
RLE: 1+ 2+ 3+ 4+ Pit Non-Pit
Edema: Present Absent Weeping
LUE: 1+ 2+ 3+ 4+ Pit Non-Pit
RUE: 1+ 2+ 3+ 4+ Pit Non-Pit
LLE: 1+ 2+ 3+ 4+ Pit Non-Pit
RLE: 1+ 2+ 3+ 4+ Pit Non-Pit
Edema: Present Absent Weeping
LUE: 1+ 2+ 3+ 4+ Pit Non-Pit
RUE: 1+ 2+ 3+ 4+ Pit Non-Pit
LLE: 1+ 2+ 3+ 4+ Pit Non-Pit
RLE: 1+ 2+ 3+ 4+ Pit Non-Pit
Edema: Present Absent Weeping
LUE: 1+ 2 + 3+ 4+ Pit Non-Pit
RUE: 1+ 2+ 3+ 4+ Pit Non-Pit
LLE: 1+ 2+ 3+ 4+ Pit Non-Pit
RLE: 1+ 2+ 3+ 4+ Pit Non-Pit
AdditionalComment:
AdditionalComment
AdditionalComment:
AdditionalComment
Respiratory Assessment
Respiratory Assessment
Respiratory Assessment
Respiratory Assessment
Rhythm: Regular Irregular Rhythm: Regular Irregular Rhythm: Regular
Irregular
Effort: Labored
Effort: Labored
Effort: Labored
Unlabored
SOB DOE
Unlabored
SOB DOE
SOB DOE
Rate: Tachy Brady Apnea Rate: Tachy Brady Apnea Unlabored
Rate:
Tachy
Brady
Apnea
Lung Sounds:
Lung Sounds:
Lung Sounds:
Anterior:
Anterior:
RUL___________________
RLL____________________
RML___________________
LUL____________________
LLL ___________________
RUL___________________
RLL____________________
RML___________________
LUL____________________
LLL ___________________
Posterior:
RUL ___________________
RLL ___________________
LUL ___________________
LLL ___________________
Posterior:
RUL ___________________
RLL ___________________
LUL ___________________
LLL ___________________
Anterior:
RUL___________________
RLL___________________
RML__________________
LUL___________________
LLL___________________
Posterior:
RUL __________________
RLL __________________
LUL___________________
LLL __________________
Other:
Other: Stridor
Other: Stridor
Rhythm: Regular Irregular
Effort: Labored
Unlabored
SOB DOE
Rate: Tachy Brady Apnea
Lung Sounds:
Anterior:
RUL__________________
RLL__________________
RML_________________
LUL__________________
LLL__________________
Posterior:
RUL__________________
RLL__________________
LUL__________________
LLL__________________
Other:
Stridor
Rub
Rub
Other:__________
Other:__________
Other:__________
Additional comment:
Additional comment:
Additional comment:
Revised 06/04/2015
Rub
Stridor
Other:__________
Additional comment:
RN Med/Surg/ICU
12
Rub
Integumentary Assessment:
Color:
Normal for Race
Cyanotic Flushed Pale
Other (describe)
Temperature: Warm
Cool
Skin:
Dry
Moist
Clammy
Other(describe):
Braden Skin Assessment
Score: _________
Integumentary Assessment:
Integumentary Assessment:
Integumentary Assessment:
Color:
Normal for Race
Cyanotic Flushed Pale
Other (describe)
Color:
Normal for Race
Cyanotic Flushed Pale
Other (describe)
Color:
Normal for Race
Cyanotic Flushed Pale
Other (describe)
Temperature: Warm Cool
Skin:
Dry
Moist
Clammy
Other(describe):
Temperature: Warm Cool
Skin:
Dry
Moist
Clammy
Other(describe):
Temperature: Warm Cool
Skin:
Dry
Moist
Clammy
Other(describe):
Additional Comments:
Additional Comments:
Additional Comments:
Additional Comments:
Wounds Assessment 1
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Wounds Assessment 2
Wounds Assessment 4
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Wounds Assessment 5
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Wounds Assessment 3
Wounds Assessment 6
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Additional Comments:
Revised 06/04/2015
Wound Care Notes /Treatments
Additional Comments:
RN Med/Surg/ICU
13
GastrointestinalAssessment
GastrointestinalAssessment
GastrointestinalAssessment
GastrointestinalAssessment
Bowel Sounds:
RUQ: Normal Absent
Hypoactive Hyperactive
Bowel Sounds:
RUQ: Normal Absent
Hypoactive Hyperactive
Bowel Sounds:
RUQ: Normal Absent
Hypoactive Hyperactive
Bowel Sounds:
RUQ: Normal Absent
Hypoactive Hyperactive
RLQ:
Normal Absent
Hypoactive Hyperactive
RLQ:
Normal Absent
Hypoactive Hyperactive
RLQ:
Normal Absent
Hypoactive Hyperactive
RLQ:
Normal Absent
Hypoactive Hyperactive
LUQ:
Normal Absent
Hypoactive Hyperactive
LUQ:
Normal Absent
Hypoactive Hyperactive
LUQ:
Normal Absent
Hypoactive Hyperactive
LUQ:
Normal Absent
Hypoactive Hyperactive
LLQ:
Normal Absent
Hypoactive Hyperactive
LLQ:
Normal Absent
Hypoactive Hyperactive
LLQ:
Normal Absent
Hypoactive Hyperactive
LLQ:
Normal Absent
Hypoactive Hyperactive
BM: Date of Last: _______
BM description__________
Nausea: Y N Flatus: Y N
Nausea: Y N Flatus: Y N
Nausea: Y N Flatus: Y N
Nausea: Y N Flatus: Y N
Abdomen: Soft Firm Round
Abdomen: Soft Firm Round
Abdomen: Soft Firm Round
Abdomen: Soft Firm Round
Tender
Tender
Tender
Tender
Non-tender
Non-tender
Non-tender
Non-tender
Additional Comment:
Additional Comment:
GenitoUrinary Assessment
Voiding: No difficulty
Hesitancy
Frequency
Unable to Void
GenitoUrinary Assessment
Voiding: No difficulty
Hesitancy
Frequency
Unable to Void
GenitoUrinary Assessment
Voiding: No difficulty
Hesitancy
Frequency
Unable to Void
GenitoUrinary Assessment
Voiding: No difficulty
Hesitancy
Frequency
Unable to Void
Color:____________
Appearance:__________
Color:____________
Appearance:__________
Color:____________
Appearance:__________
Color:____________
Appearance:__________
Bladder Scan Y N
amount_____
Mode of Elimination:
BRP BSC Bedpan
Urinal Foley Incontinent
Additional Comments:
Bladder Scan Y
amount_____
Bladder Scan Y
amount_____
Bladder Scan Y
amount_____
Mode of Elimination:
Bedpan BSC BR
Rectal Tube
Stoma
Other: ________
Additional Comment:
Additional Comment:
Revised 06/04/2015
N
Additional Comments:
N
Additional Comments:
N
Additional Comments:
RN Med/Surg/ICU
14
Safety/ Environment
Side rails: Down 1Up
2Up 3 Up 4 Up
Safety/ Environment
Side rails: Down 1Up
2Up 3 Up 4 Up
Safety/ Environment
Side rails: Down 1Up
2Up 3 Up 4 Up
Safety/ Environment
Side rails: Down 1Up
2Up 3 Up 4 Up
Bed Position: Low High
Bed Position: Low High
Bed Position: Low High
Bed Position: Low High
Pt Position:_______
Pt Position:_______
Pt Position:_______
Pt Position:_______
Bed Lock: Y N
Bed Lock: Y N
Bed Lock: Y N
Bed Lock: Y N
Restraints:
Type: __________
Location of restraints:
________________
Restraints:
Type: __________
Location of restraints:
________________
Restraints:
Type: __________
Location of restraints:
________________
Restraints:
Type: __________
Location of restraints:
________________
Assess
q15min
q2hrs
and
Document: Assess
(Behavioral) q15min
(medical)
q2hrs
and
Document: Assess
(Behavioral) q15min
(medical)
q2hrs
and
Document: Assess
and
(Behavioral) q15min
(medical)
Document:
(Behavioral)
q2hrs
(medical)
Additional Comments:
Additional Comments:
Additional Comments:
Additional Comments:
IV SITE
Assessment____________
_____________________
_____________________
IV SITE
Assessment____________
_____________________
_____________________
IV SITE
Assessment____________
_____________________
_____________________
IV SITE
Assessment____________
_____________________
_____________________
Change in gtt status:
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Change in gtt status:
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Change in gtt status:
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Change in gtt status:
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
CVP Reading:_______
Art Reading:________
CVP Reading:_______
Art Reading:________
CVP Reading:_______
Art Reading:________
CVP Reading:_______
Art Reading:________
Revised 06/04/2015
RN Med/Surg/ICU
15
Shift Report
(i.e. how this client’s assessments cares would be documented on paper)
S________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
B________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
A________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
R________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
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Clinical Day Priority Nursing Diagnosis
□What is this client’s first priority nursing diagnosis for this shift?
Example (Nursing Dx R/T_________AEB_________).
______________________________________________________________________________
______________________________________________________________________________
□What is the goal for this client with regards to this nursing diagnosis? (SMART Goal)
Client will:
LT goal
______________________________________________________________________________
ST goal
______________________________________________________________________________
□ List 5 nursing interventions and rationales for this client in order to meet this goal.
Interventions
Rationale
EVALUATION OF GOAL:
□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal
could be revised.)
________________________________________________________________________________________
MODIFICATION:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
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Clinical Day Priority Nursing Diagnosis
□What is this client’s first priority nursing diagnosis for this shift?
Example (Nursing Dx R/T_________AEB_________).
______________________________________________________________________________
______________________________________________________________________________
□What is the goal for this client with regards to this nursing diagnosis? (SMART Goal)
Client will:
LT goal
______________________________________________________________________________
ST goal
______________________________________________________________________________
□ List 5 nursing interventions and rationales for this client in order to meet this goal.
Interventions
Rationale
EVALUATION OF GOAL:
□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal
could be revised.)
________________________________________________________________________________________
MODIFICATION:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
18
Shift Documentation
(hour by hour account of patient careNOT WHAT U DID)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Revised 06/04/2015
RN Med/Surg/ICU
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