Student: _____________________ Date of Care: A. Identifying DataPatient Initials: Age: Gender: _Allergies: _________Primary Language: Ethnicity: Religion:Marital Status: _ Occupation: _Insurance: Family Composition: Home/Living Situation: __________Date/s of Care: _Date of Admission: Date/s of Surgery:_Physician(s)/Specialty: _Admitting Diagnosis/es: Surgical Procedure(s) this hospitalization: ________________________B. Biological1. Past Medical/Surgical History/Chronic Conditions:(Provide date of onset and/or diagnosis for each condition)2. Recent Medical History/Reason for Admission/Course of Hospitalization:(Discuss all related details that led to the pts. admission to the hospital up until the moment you assumed pt. care on your shift. This tells the story of current stay)3. Home Medications: *Provide name, dose, frequency and WHY the pt. needs the****medication based on their medical history & chronic conditions:*Generic/Trade NameDoseFrequencyPurposeAdd to table as needed. All home meds must be included.4. Definition of Medical Diagnosis with patient’s signs & symptoms at time of admission:5. Physical Assessment:**Ht _ Wt BSA BMI ______

School of Nursing: Pathophysiology

Nursing Process Data Form

Pathophysiology

Head-to-Toe Assessment

VITAL SIGNS/HEMODYNAMICS:

INTAKE AND OUTPUT Past 24º Balance _+/-__________

Medications

Routine/PRN Medications

INTEGUMENTARY:

MUSCULOSKELETAL:

NEUROLOGICAL:

GASTROINTESTINAL:

GENITOURINARY:

2. At least three Evidenced Based Research Article

Student: _________________________

Date: ___________

Time	Temp F/C	Pulse (apical/radial)BPM	Resp/min	BP in mmHgR or L	Pulse Ox %
				/
				/
				/
				/

PAIN ASSESSMENT:

LABORATORY DATA:

TEST	NORMALVALUE	RESULTS	RESULTS	RATIONALE FOR ABNORMALS
CHEMISTRY		Date / Time	Date / Time	State the reason why this pts. lab values are abnormal
Na
K
Cl
Mg
HCO3-
Glucose
BUN
Creatinine
T. Protein
Albumin
Uric Acid
Calcium
Phosphorus
Bilirubin
Alk Phos
ALT (SGPT)
AST (SGOT)
LDH
Cholesterol
LDL
HDL
Troponin
CPK isosMM, MB, BB
CBC	Normal	Date/Time	Date/Time	Rational for Abnormals:
Hgb
Hct
WBC
RBC
Diff
Plates
PT/INR
PTT
Other	Normal	Date/Time	Date/Time	Rational for Abnormals:
C & S
Cultures

ARTERIAL BLOOD GASES:

ABGs	RESULTSDate / Time:	RESULTSDate / Time:
pH
pO2
O2 Saturation
pCO2
HCO3
Overall Interpretación:

DIAGNOSTIC TEST & PROCEDURES:

(Include 12 Lead EKG, CXR, Cardiac Cath, CT, MRI, Ultrasound, Endoscopy, Echocardiogram, etc)

Test:	Pt. Results:(Date/Time)	Normals:(referenced)	Rationale For Test Being Performed On This Patient:	Rationale for Abnormal Test Results:

Does the patient have a positive or negative fluid balance as of this date? How much?______ML

Intake	1º	12º	Output	1º	12º
PO / Enteral			Source:
IV
Blood Products

IV Solutions/Parenteral Nutrition/Blood Products :

Name of Infusant:	Rate:	Site:(describe the appearance)
IV Solution:
Lipids/TPN:
Blood Products:

List all the patient’s medications ordered. Why would THIS patient have this medication specifically? Consider diagnosis, medical history, lab values, procedures when discussing the rational for each medication.

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Efect:
Nursing Implications:
Pt/Fam teaching needs:

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Efect:
Nursing Implications:
Pt/Fam teaching needs:

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Efect:
Nursing Implications:
Pt/Fam teaching needs:

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Efect:
Nursing Implications:
Pt/Fam teaching needs:

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Effect:
Nursing Implications:
Pt/Fam teaching needs:

Medication:	Dose:	Route:	Frequency:
Classification:
Action:
Safe dose range for age/wt:
Rational for use in THIS patient:
Desired Effect:
Side Effects:
Toxic Efect:
Nursing Implications:
Pt/Fam teaching needs:

**Continue to copy the above chart as often as needed to include ALL Routine & PRN

meds**

Skin: Color __________ Turgor __________ Temp __________ Moisture ___________

Lesions ________________________________________________________________

Incisions__________________________________ Dressings _____________________

Varicose Veins ______________________ Scars _____________________ Nails _____

Pressure Ulcer: Location __________________ Stage _____________ Characteristics _______________________________________________________________________

Unusual Pigmentations/Tattoos/Piercings___________________________________

Drainage/ Suction ________________________________________________________

Dressings (describe each by site, size, appearance,characteristics, drainage, etc.) ____________________________________________________________________

Note: *Labs & Medications for the integumentary system must be address here

Activity Level __________ROM __________Gait/Mobility __________ Posture __________

MuscleTone/Strength __________________________________________________________

Any Contractures______________________________________________________________

LUE____________ RUE_______________ LLE_________________ RLE_________________

Assistive Devices ________________________Prosthesis/es___________________________

Other Devices_________________________________________________________________

Frequent position of pt. on your shift_______________________________________________

Note: *Labs & Medications for the musculoskeletal system must be address

Level of consciousness, alertness, orientation, cognition memory (short/long term) _________________________________________________________________________

Sleep/rest patterns _________________________________________________________

Speech __________________________________________________________________

Sensory (taste, smell, touch)_________________________________________________ _________________________________________________________________________

Motor (fine/gross) __________________________________________________________

Vision ____________________________________________________________________

Hearing ___________________________________________________________________

Reflexes ____________________________________________________________________

Cranial Nerves (All must be included, how tested & results) ________________________________________________________________________

Note: *Labs & Medications for the neurological system must be address

CARDIOVASCULAR:

Heart Sounds ________ Rate ____________ Rhythm ____________ Apical ________

Pulses: R/L Radial ___________ Brachial ________Femoral ______DP_____ PT ____

Capillary Refill ________________________ Skin color/temp _____________________ Edema/Location___________________________________________________________

Shunts/Location (bruit, thrill)_________________________________________________

Note: *Labs, Vitals & Medications for the cardiovascular system must be address

PULMONARY:

Respirations:

Rate/Min ______ Rhythm_______ Depth______ Effort/Ease_______ Pulse Ox __________

Breath Sounds (all lobes & bilateral comparison) R/L – Crackles (fine, coarse) Wheezes (inspiration, expiration), Diminished, Absent _________________________________________

Sputum/Secretions ______________________________________________________________

Oxygen Therapy/Rate:_______________________ Via_________________________________

RT Treatments (type, frequency)______________________ _____________________________

Chest Tubes _________________ Suction __________________ Drainage ________

Note : *Labs, Vitals & Medications for the pulmonary system must be address

Diet__________________ Appetite ________________ Intake% ___________N/V ____

Kcal per day needed _________________________ receiving ___________________

Enteral nutrition: NG Tube _________________ G Tube ________________ J Tube _________

Mouth /oral mucosa______________________________Teeth/Dentures___________________

Abdomen: (soft, distended, ascites, stomas): _________________________________________

Bowel sounds: Location____________________ Activity________________________________

Bowel Patterns ______________ Last BM ___________ Stool Characteristics _______________

Note: *Labs & Medications for the gastrointestinal system must be address

Urine: Output (hourly, 8º, 12º, 24º) ___________ Characteristics __________________

Patterns of voiding _____________________________________ Catheter (type) ______

Genitalia: Female______________________________ Male_______________________

Sexual History (if applicable) _______________________________________________

Childbearing History (if applicable):__________________________________________

Note: *Labs & Medications for the genitourinary system must be address

6. Clinical Manifestation of Current Condition(s):

Expected Manifestations. According to Literature for *Each Medical Diagnosis and Surgical Procedure.* Must be referenced and cited per APA	Assessment findings on Day of Care r/t each diagnosis. Include vitals, labs and physical assessment data(Date)___________
Dx #1:Dx #2:Dx #3:	Dx #1:Dx #2:Dx #3:

7. Patient Care Needs on your shift: (Discus your focus/concerns /care for the day)

8. Pathophysiology (Discuss pathophysiology of patient’s current and relevant past medical/surgical problems. Integrate with clinical data such as vital signs, labs, diagnostic test, procedures, medication use, and family history) Most patients have multiple diagnosis, ONE must be discussed:

Integrate textbook details with specifics of your patient. Make this very specific to the patient you have cared for. Cite references per APA (This generally requires 2 pages MINIMUM, double space)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Potential Complications (based on pathophysiology & referenced):

Medical Diagnosis:	Potential Complication:
Dx #1
Dx #2
Dx #3

10. Nursing / Medical Therapies and Treatments:

(Utilize Potter and Perry& Lewis textbooks. Cite all rational & nursing implications)

Treatment	Rationale for Treatment / Patient Application	Nursing Implications	Frequency

This should be a comprehensive list of all the care provided to your patient during your shift. It may be care offered by other disciplines or by nursing. Examples include: ADL’s, ambulation, ROM, feeding, I&O, Vitals, Med pass, documentation. PT, ST, RT, OT, MD visit, repositioning, dressing changes, pt/family education, emotional or spiritual care, visit from chaplain, etc. etc. ALL care provided to a patient requires some level of nursing assessment and monitoring and has a nursing implication. This chart is designed for you to explain how busy you were providing outstanding care to your patient.

1. Individual/Family Developmental Stage and Family Dynamics:

C. Psychosocial Subsystem

(Discuss stages per Ericson and Maslow with rational based on your assessment of pt)

2. Cultural Influences/Health Beliefs and Values:

(Provide general information regarding pts identified culture first)

3. Individual/Family Challenges VS. Individual/ Family Strengths

Individual/Family Challenges	Individual/Family Strengths
1.	1.
2.	2.
3.	3.

4. Individual/Family Coping with the Current Stressors:

D. Spiritual Subsystem

1. Spiritual Assessment: {Ref. Taylor (2002); Potter & Perry (2013), Articles for a variety of spiritual assessment tools that can be used. Student must identify the specific model/tool/assessment used, the questions asked and the patient’s response including patient’s own words in quotations}

Spiritual Strengths	Spiritual Resources	Spiritual Needs
1.	1.	1.
2.	2.	2.
3.	3.	3.

5. Link between spiritual assessment findings and overall health of patient:

Note: This is a great place to integrate the required research article, then link to specific patient issues

UNRS 367 / J. David

Community Referral, Follow-up Appointments, Medications, Treatments, Equipment, Support Groups, Home Health Needs and Long Term Care Concerns.

Educational Needs	Evaluation of Teaching	Medications/Treatments/Equipment	Referrals / Follow-up / Disposition

Provide a list of names and contact information in the patient’s neighborhood, for necessary support groups or other types of resources that might be required by patient upon discharge:

G. References and Reference list per APA guidelines

1. At least one general clinical or specialty article

a) Use articles from peer reviewed professional journals.

b) Must include copy of the article.

a) Three research article required for full credit.

b) Include a copy of all the articles used to obtain credit.

c) Write a brief statement on how a research article was applied to nursing care for this specific patient.

3. Formatting & Appearance of completed work

a. APA format

b. Pagination

c. Title & Running header

d. Margins

e. Quotations

f. References

g. Spelling

h. Grammar

Pain Tool Used

Pain Rating

Pain Description (OLDCART)

Functional Pain Goal

PainMedication (or other care)

Response ToIntervention