PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week:

Dates of Care:

Patient Initials	Sex	Age	Room	Admitting Date	Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Attending physician/Treatment team:	Consults:
Present Diagnosis: (Why patient is currently in the hospital)	ER Management: (if applicable)
Allergies:	Code Status:	Isolation: (type and reason)
Admission Height:	Admission Weight:	Arm Band Location (colors & reasons)
Communication needs: (verbal, nonverbal, barriers, languages)
Past Medical History: (pertinent & how managed)
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day) Time T P R B/P Time T P R B/P	GI: Diet: Swallow precautions: Tube feedings: NG / G tube: Blood Glucose: (time & date) Last bowel movement: (time & date) Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Respiratory: 02 modalities: 02 Saturation: Suction: Resp Rx’s: Trach: Chest Tubes: Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB)	Neurosensory: Neuro checks: Alert & Orientated: Follows commands: Speech Comprehensible: Pertinent Labs/Test: Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Cardiovascular: Telemetry: Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)	Musculoskeletal: Activity: Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
Renal: Catheter (indwelling/external): CBI: Dialysis: A/V access: Pertinent Labs/Test: Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)	Skin: Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
Pain: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions)	Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge)	Post-operative /procedural: Assessments/Interventions: (immediate post procedure care)
Safety: Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient)	Advance Directives/Ethical considerations: DPOA: Hospice:
Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC RBC HGB HCT MCV MCH MCHC Platelets RDW MPV PT INR APTT Glucose BUN Creatinine Sodium Potassium Cloride Calcium T Protein Albumin SGOT SGPT Alk Phos Magnesium Amylase Lipase CPK LDH Cholestrol CK CK-MB Troponin I Myoglobin LDI Urinalysis Color Character Spec. Grav. pH Protein Glucose Acetone Bilirubin Blood Nitr Urobili RBC WBC Epithelium Urine Culture Chest X-ray MRI CT Scan Others test:
Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)
Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1
2
3
4
5

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)	Patient Goal(s) Statement of purpose for the patient to achieve	Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes)	Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.	Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)	Patient Goal(s) Statement of purpose for the patient to achieve	Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.) (Must have at least two short term outcomes and two long term outcomes)	Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.	Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

PAGE

1