Nursing process worksheet
Room Patient/Age/Sex Attending & consults Allergies Admit date Primary diagnoses Isolation & organism Code status Past medical hx CC/HPI Past surgical hx Neuro/Psych GCS Labs Primary language Eyes _____ Level of consciousness Verbal _____ WBC Orientation & follow commands Motor _____ Mood/behavior Total _____ Pupils Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____ BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____ Plt Hgb Hct Ca Mag Glu Na Cl BUN K CO2(HCO3) Cr Bili Cardiac Echo EF _____ % Heart rate trends Tele rhythm trends SBP/MAP trends & goal parameters Temp trends & method/fevers & Tmax Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____ Edema & grading [ ] Pacemaker / [ ] AICD Respiratory IS [ ] & trends/max _____ ml Lung sounds & work of breathing/rhythm O2 delivery _____ @ _____ LPM / _____% O2 sat trends Secretion amt & character/suction method Chest tube(s) output & character ABG date _____: pH _____ / pCO2 _____ / HCO3 _____ / pO2 _____ GI Lt NG / Rt NG taped @ _____ cm / PEG Continent/incontinent Suction __________ / Output _____ ml Last BM & character Current TF rate @ _____ ml/hr Bowel sounds TF goal rate _____ ml/hr Abdomen appearance & palpation TF max residual _____ ml Diet/TF formula Rectal tube/colostomy output & character Fluid restriction _____ ml/day GU Foley insert date _____ Indication __________ Continent/incontinent Last bladder scan _____ ml @ _____ Voiding method Last I&O cath _____ ml @ _____ Shift/hourly urine output Urine character HD sched __________ & last HD amt removed _____ ml Musculoskeletal/Safety & Mobility [ ] SCDs [ ] VTE ppx meds Pain & scale utilized Assistive devices Level of assist Calls for assist/safety concerns Restraint type & location Sitter/tele-sitter Rehab consults: [ ] PT [ ] OT [ ] SLP Skin & Drains/Tubes Pressure injuries/wounds Wound tx/dressings output & character Drains/tubes output & character Wound care consult [ ] IV Lines 1 2 3 4 5 6 7 8 Continuous IV Drips 1 2 3 4 5 6 7 8 ALT AST Phos INR PT aPTT Alk Phos Alb GFR ________ HgbA1C ________ Troponin ________ Lactate ________ BNP ________ Procal ________ CK ________ CRP ________ D-dimer ________ ESR ________ Fibrinogen ________ Amylase ________ Ammonia ________ Lipase ________ UA _________________________________ Cultures ___________________________ ____________________________________ Diagnostics/Imaging 12-lead ECG XR CT MRI Ultrasound EEG Specialty: Advanced Med/Surg Neuro/Psych – Richmond Agitation-Sedation Scale RASS Cardiac – Hemodynamics PA cath @ _____ cm CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____ Respiratory – Artificial airway & mechanical ventilation ETT size _____ taped @ _____ cm @ teeth / gum / lip Trach brand __________ & size _____ Vent mode ____________ Rate _____ VT/PS _____ FiO2 _____% PEEP _____ GI – Enteral tube OG taped @ _____ cm OTOs/PRNs given & time last given To-do/Follow-up/Notes Shift Notes 07/19 Vitals 08/20 09/21 08/20 12/00 16/04 10/22 Temp & source HR & rhythm 11/23 12/00 13/01 14/02 BP & MAP Resp rate 15/03 16/04 17/05 18/06 SpO2 & delivery method Pain & pain scale used Medication Administration Record – provide 5 most critical/priority medications Generic & trade name Pharm class Dose Route Freq Indication(s) r/t patient Common SEs/ADEs (at least 3) Nursing considerations (at least 3) Plan of Care (Clinical Judgment Plan) Priority problem #1 [hypothesis]: Priority problem #2 [hypothesis]: Priority problem #3 [hypothesis]: Pertinent assessment data [cues]: Pertinent assessment data [cues]: Pertinent assessment data [cues]: S.M.A.R.T. goal/outcome #1 [solution]: S.M.A.R.T. goal/outcome #2 [solution]: S.M.A.R.T. goal/outcome #3 [solution]: Interventions with frequency & rationale [actions]: Assess/monitor: Interventions with frequency & rationale [actions]: Assess/monitor: Interventions with frequency & rationale [actions]: Assess/monitor: Manage: Manage: Manage: Educate: Educate: Educate: Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):
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