Student name: 						Date of Care:				
History of Present Illness (HPI)
Patient Initials: 		  Pt Age: 	  Gender:	   Date of Admission: 			

Review the last 24 hours of nursing notes and the admitting physician’s history and physical exam to answer the items below, summarize the notes you read in your own words. 

Tell the story of how your patient ended up in the hospital:   (1pt)

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)

Social History   (1pt)
Occupation:
Lives with?
List family members involved with your patient’s care.
Habits (Tobacco/Alcohol/ Drugs)

Nursing Care:    (1 pt)
Isolation
Code Status:  Full or DNR
Pain
Fall Risk
Hygiene
Activity
Diet
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)

Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt)

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).

What laboratory tests and diagnostics are used to diagnose this pathology, identify below which ones your patient has done and relate the results to the pathology. (5pts)
Laboratory Testing
     Hematology Value	Normal	If not, why?  Please relate to the disease process
	WBC
	RBC
	Hgb
	HCT
PLT
INR
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na
	K
	Cl
	BUN
	Cr
	Glucose
	Other
    Urinalysis

Diagnostic Imaging:
a.	In your own words why is this test done- relate it to the pathology
b.	If abnormal, what changes in your nursing care need to be made?
     Chest X-ray:
     ECG / Telemetry
     CT (Cat Scan)
     MRI
     Ultra Sound
     Other:

Medications
List all medications your patient has used in the last 24 hours including: 
1.	Medication name (generic) with prescribed dose & frequency, 
2.	The usual dose & frequency, 
3.	Classification & mechanism of action, 
4.	Why this medication is being used for this patient, 
5.	What nursing precautions considerations do you need to know to SAFELY administer / monitor this medications and lastly 
6.	Evaluate the medications effectiveness for this patient (patient response).  (10 pts)

Name (generic) 
prescribed dose 
& frequency, 
usual dose & frequency	Classification/
Mechanism 
of action	Why use this 
medication 
for this 
patient?	Nursing precautions/ 
safety considerations
To administer this medication	Evaluation
Patient response	

					

					

					

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)  (5 pts)     All subjective 
& objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:	BP:	Pulse:
Rate:
Rhythm:	Respirations:
Rate:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    Characteristics:          	Ht: _________
Wt: _________	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	

GASTROINTESTINAL:
Diet at home :                 Current Diet:   
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________		
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________		
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            	
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	

	
PSYCHOSOCIAL/CULTURAL:
Educational level
Developmental level       
Coping methods          
Health Beliefs
Occupation (previous if retired)
Religion & what it means to pt.
Personal/Family Data    (Think about home environment, family structure, and available family support)	

USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Other: Priority Nursing Diagnosis: (Use NANDA format) (2pts)

What does the patient/client need to accomplish?
GOALS/OUTCOMES
(2pts)
Measurable patient centered goals are identified, realistic and contain a time element.
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions
(2pts)
Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format
(2pts)
Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 
(2pts)
Includes all the following: 
1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 
3. Modifications to the plan of care.	

				
Reference List for all references used in this document.     Use APA format.          (1 pts)