Past Medical History:

Vital Signs: Temp HR RR BP O2Sat Pain 8:00 AM 12:00 PM Fluids and Nutrition: Activity/mobility: Diet: ADLs I&O IV Rx Assistive devices Elimination: Oxygen Therapy: Bowel (LBM) Bladder Other: Discharge Plans/Teaching Needs: Diagnostic Tests (as available) Hematology Test Norms Results/Date Analysis/Interpretation for Patient RBC WBC Hct Hgb Diagnostic Tests (as available) Chemistry Test Norms Results/Date Analysis/Interpretation for Patient Na K Cl Glucose BUN Creatinine Other Significant Diagnostic Tests Test Name Norms Results/Date Analysis/Interpretation for Patient Functional Health Patterns (Identify Typical and Current Patterns at Home & in Hospital) NUTRITION-METABOLIC (usual daily food/ fluid intake; preferences; appetite; shopping/cooking): ELIMINATION (bowel/ bladder, usual pattern, problems, aides): ACTIVITY-EXERCISE (ADLs; leisure; amt./type of regular exercise): SLEEP-REST: (bed/rising time, naps, feels rested or not, sleep aides) SEXUALITY-REPRODUCTIVE: (intimacy/concerns, breast/testicular screening, menses/pregnancy/menopause) HEALTH PERCEPTION-HEALTH MANAGEMENT: (understanding of illness, cultural influences, measures to maintain health, risk factors for disease) COGNITIVE-PERCEPTUAL (memory; decision-making, sensory function; pain & its management;): SELF-PERCEPTION (attitude about self: body image; identity; eye contact): COPING-STRESS-TOLERANCE (how stress handled; resources, cultural influences): VALUE-BELIEF (religion/culture; conflicts between health & beliefs): ROLE-RELATIONSHIP (occupation, family/ social relationships/responsibilities): PHYSICAL ASSESSMENT* GENERAL APPEARANCE: SKIN/HAIR/NAILS: FACE/HEAD/NECK: EYES/EARS/NOSE/THROAT: RESPIRATORY: CARDIOVASCULAR: GI/ABDOMEN: GENITOURINARY: BREASTS: MUSCULOSKELETAL: NEUROLOGICAL: Problem List/Statement: Problem List: (rank in order of priority) Priority Problem Statement: Outcomes: (Patient/family focused; identify the evaluation criteria you will use) Short-term: Long-term: Planning and Implementation: Nursing Intervention(s) Rationale Evaluation: (state if the desired outcomes were achieved or not achieved; if not, what interventions might be implemented to achieve the outcome) Patient’s Medications Name & Classification Prescribed Dose & Recommended Dose Drug Action Reason the patient is on this medication Side Effects Nursing Implications                                                            

Sample Solution