FULTON-MONTGOMERY COMMUNITY COLLEGE NURSING PROGRAM Student: Pt. Init. Rm.

Age: Allergies: Sex: Religion:

List & Define Medical/Surgical Diagnoses:

Normal Anatomy/Physiology of affected system(s):

Pathophysiology of affected system(s):

History and Assessment Data (Include Medications, Treatments/Medical Orders, Diagnostic Tests, IV Therapies) DATA Neurological Temperature: Mental/Emotional status: Response Orientation: time Place Person Affect: Sensory Status: Speech: Vision: Hearing: Smell: Ability to communicate: Signs of discomfort: Significance of Data

DATA Respiratory Respirations: Rate: Rhythm: Depth: Quality: Breath sounds: Color: Facial: Lips: Mucous membranes: Nailbeds: O2 equipment:

Significance of Data

DATA Cardiovascular Radial pulse: Rate: Rhythm: Intensity: Apical pulse: Rate: Rhythm: Intensity: Blood Pressure: _____arm Capillary refill: Pedal pulses: Dorsalis Pedis: Post Tibial: Condition of extremities: Color: Edema: Temperature:

Significance of Data

DATA Gastrointestinal/Nutrition Appetite: Diet Order: Dietary intake: Food: Fluids: Non- oral method of feeding: Mouth: Condition of teeth: Gums: Mucous membranes: Hydration: Crusts: Lesions: Ability to swallow: Abdomen: Bowel sounds: Bowel control: Frequency: Continence: Hemorrhoids:

Significance of Data

DATA Renal/fluid and electrolytes Kidney disease: Kidney stones:

Significance of Data

DATA Musculoskeletal Mobility of head/neck: Muscle strength: Right: Upper: Lower: Left: Upper: Lower: ROM: Right: Upper: Lower: Ability to change position/mobility Ability to perform own ADLs

Significance of Data

DATA Integumentary Skin temperature: Turgor: Color: Rash: Lesions: Edema: Skin folds: Hair: Nails:Fingers: Toes:

Significance of Data

DATA Psychosocial Religion: Marital status: Past occupation: Role/relationship

Significance of Data

DATA Genitourinary/Reproductive Bladder control Frequency: Continence: Color: Odor: Characteristics of urine: Genitalia: Breast tenderness or lumps

Significance of Data

DATA Endocrine Blood glucose results (if ordered)

Significance of Data

Diagnosis (PES), PE) Collaborative Problem:

Patient Outcome Criteria or Goal

Nursing Interventions

Rationale

Diagnosis (PES), PE) Collaborative Problem:

Patient Outcome Criteria or Goal

Nursing Interventions

Rationale

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Diagnosis (PES), PE) Collaborative Problem:

Patient Outcome Criteria or Goal

Nursing Interventions

Rationale

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Diagnosis (PES), PE) Collaborative Problem:

Patient Outcome Criteria or Goal

Nursing Interventions

Rationale

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LIST/PRIORITIZE ALL ADDITIONAL Nursing Diagnoses/Collaborative problems: (Do not include those already developed in the Nursing Care Plan)

References

Nurses Note (Documentation): You will be required to write a nurses note regarding your patient(s). This will be critiqued by your instructor.

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