Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes;
Student Name: Date:
| Client Data: | ||||||
| Initials: | Age: | Gender: | ||||
| Weight: | Height: | Race/Ethnicity: | ||||
| Diet: Regular | Religion: | Room Number: | ||||
| Allergies | Marital Status: | Code Status: | ||||
| Past Surgeries: | Consults: | Social Habits: | ||||
| Vital Signs: | ||||||
| B/P: | P: | R: | T: | SAO2 sat: | ||
Present History: Admitting Medical Diagnosis:
A. Why client is in hospital:
Admitting Diagnosis Information:
Definition/Etiology/Pathophysiology:
Clinical Manifestations/signs and symptoms:
Medical Management:
Past History/Secondary Diagnosis:
Definition/Etiology/Pathophysiology:
Clinical Manifestations/signs and symptoms:
Medical Management:
List of Medications
| Medication Name/ Frequency | Indication | Actions | Contraindication | Side Effects | Nursing Implication |
| | | ||||
| | |||||
| | |||||
|
| | ||||
| |
Labs and Diagnostic Test:
| Labs and Diagnostic Test/Labs | Purpose/ Indications | Normal Values | Client Result | Interpretation of abnormal results |
|
| ||||
2 more Nursing Diagnosis with Interventions and Rationales
Concept Map after this page
Works Cited
