CSM PATIENT CARE WORKSHEET
Student: ________________________________
Date: ___________________________
Patient’s Initials: ________ RM#: ______ Age: _____ Sex: _____ Religion: ____________________
Code Status: ____________
HIPAA: _____________
Admission Date: ___________ Family Role: __________________ Occupation: ____________________
Primary Medical Diagnoses/Surgical Procedures: _____________________________________________
Dev.
Secondary Medical Diagnoses: _____________________ Stage/Task: ____________________________
Identified Teaching Needs:
Is this patient at appropriate developmental
level for age?
Patient Teaching Goal:
Ethnic/Cultural Implications:
Discharge Goal:
Safety Issues:
BATH
Bed
Self
Shwr
Tub
Sitz
Partial
ACTIVITY
Bed
BRP
BRP c Asst
Chair
Amb c Asst
Amb Ad Lib
http://consultgerirn.org/topics/ethnogeriatrics_and_cult
ural_competence_for_nursing_practice/
DIET
FLUIDS
Reg
Limit
Soft
Sips
Cl Liq
Ice Chips
Full Liq
Push
NPO
Intake =
Special Diet: _____ Output =
CHECK
Blood Sugar
Wt: ______
Foley
Specimen: ____
EQUIPMENT BEING USED
IV Fluids: Type: ______________ IV Balance: _________ ________ Rate of Flow: ________ ________
(Beginning)
(Ending)
(ml/hr)
(gtts/min)
IV Site Assessment: ____________________________ Tubing Change (date to be done): _______________
Allergies:
Treatments/Therapy
(lab, radiology, special procedures, etc.)
Time
Date
S:
Test
Results
Diagnostic Tests Scheduled For Today:
B:
A:
R:
Significant Diagnostic Data
Significance
Project Course Related:
Prioritize
System ASSESSMENT CRITERIA
INTEG: color, temp, moisture,
turgor, integrity, scars, incisions,
lesions (measure)
NEURO: A&O x 4, PERRLA,
T=
symmetry, facial expressions,
EOMs, fine/gross motor fxn, MAE,
grips, sensation, speech, strength
*RESP: rate, rhythm, depth,
R=
effort, breath sounds, O2 sat,
incentive spirometry, m.
membranes
*CV: pulses, capillary refill,
B/P=
edema, CSM
*GU: amount, urine
characteristics, bladder
distention, ext. genitalia
GI: intake, appetite, BM, bowel
sounds, distention
*MS: ROM, spine, MAE, strength
ASSESSMENTS/OBSERVATIONS
Day 1
Day 2
T=
R=
Apical P=
Radial P=
B/P=
EENT: vision, glasses, ENT
discharge, hearing, hearing aid,
dentures, nares,
lymphadenopathy
EMOT/PSYCH: affect, mood,
cooperation, family support
systems
PAIN: location, intensity,
characteristics, pharmacological
and nonpharmacological
interventions
SLEEP/REST:
http://consultgerirn.org/topics/s
leep/want_to_know_more/
*Include any accessory equipment used on patient (monitor, 02, foley)
Primary Patient Goal:
TIME
PLAN
TIME MANAGEMENT PLAN
ANALYSIS OF DAY
Apical P=
Radial P=
PATIENT CARE PLAN
DATA
[Indicate subjective (s)
&
objective (o)]
#1
#2
NURSING
DIAGNOSIS
Goals
(short and long term)
O. CRITERIA
(with deadline)
N. INTERVENTIONS
(Rationale with
references)
EVALUATIONS
Time
Medication Dosage/
Frequency/Route
Reason/Parameters
Side Effects/Nursing
Implications