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InterCoast Career Institute

Clinical Prep Sheet for Terms II, III, and IV

Patient (Initials): Age: Gender: Room: Code Status:

Sociocultural/Spiritual: Physician:

Primary Nurse: Patient Care Assistant:Primary Diagnosis / Date:

Surgeries: Smoking Hx:

Other Diagnoses:

Role/Developmental Stage:

Diet: Activity level: Hygiene:

Parenteral Therapy:

VS: BP Pulse: Respirations: Temperature:

P O2: O2 Therapy: Blood Glucose:

Allergies:

Mental Status: Pain Scale:

Respiratory Status/Breath Sounds:

Urinary Function: and I and O Foley:

Bowel Pattern and Bowel Sounds:

Transfer:

Treatments/Interventions: INITIALS

MEDICATION DOSE TIMES REASON

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NURSES ASSESSMENT

Patient Name:

Date/Time:

Respiratory Status

DysphasiaLung Sounds

O2

Musculoskeletal Status

Activity Tolerance/MobilityMobility Transfers

Ambulation

ROM

ADLs (independent, Partial, or Total Assist)Weight Bearing StatusAssistive Devices

Progress with Therapy

Cardiac Status

Chest PainSkin Color

EdemaCerebrovascular Status

Level of ConsciousnessOrientation

Pain

Location

How Relieved, etc.

Wound

Type/LocationAppearance

Drainage/OdorDsg./Treatment

Ulcer Care

GI/GU

Appetite, Bowel SoundsN/V/DCatheter

Continent/Incontinent

Medication

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Nurses Notes:

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Patients Initials: Date: Students Name: Catherine Harman 4

MODIFIED CARE PLAN

IDENTIFIED NURSING DIAGNOSIS #1

NURSING INTERVENTIONS (what?) RATIONALE (state reference) (why?) EVALUATION (results?) (outcome)

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Patients Initials: Date: Students Name: Catherine Harman 5

MODIFIED CARE PLAN

IDENTIFIED NURSING DIAGNOSIS #2

NURSING INTERVENTIONS (what?) RATIONALE (state reference) (why?) EVALUATION (results?) (outcome)

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Patients Initials: Date: Students Name: Catherine Harman 6

MODIFIED CARE PLAN

IDENTIFIED NURSING DIAGNOSIS #3

NURSING INTERVENTIONS (what?) RATIONALE (state reference) (why?) EVALUATION (results?) (outcome)

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Patients Initials: Date: Students Name: Catherine Harman 7

MODIFIED CARE PLAN

IDENTIFIED NURSING DIAGNOSIS #4

NURSING INTERVENTIONS (what?) RATIONALE (state reference) (why?) EVALUATION (results?) (outcome)

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Patients Initials: Date: Students Name: Catherine Harman 8

Disease and Disorders Research

Include Disease And Disorders Research Sheet For Each Patients Medical DiagnosisMedical Diagnosis Research

Disease Or Disorder Alzheimers Type Dementia Patients Signs and SymptomsCommon Signs And Symptoms yy y

Pathophysiology Of Disease And/Or Disorder

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Patients Initials: Date: Students Name: Catherine Harman 9

Lab Results Possible Findings Because ofCondition

Patients Lab Results Significance (in regards to yourpatient)

Common DiagnosticTest And Procedures

Possible Findings Because OfCondition

Patients Diagnostic Tests AndProcedures

Test And Procedure Results

Commonly Used Medications Rationale for Use Medications Order for Patient Result Of Medication For Patient

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Patients Initials: Date: Students Name: Catherine Harman 10

Specific Nursing Actions Needed For This Patient

Problem Nursing Action (what are you going to do for your patient)

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Patients Initials: Date: Students Name: Catherine Harman 11

Physiological Integrity

Patients Medical Diagnosis DietaryPrescription

Patient Care And Comfort Interventions Reduction Of Risk Interventions

Food And Fluid

Intake Data

Day 1 Day 2 Day 3

PHYSIOLOGICAL ADAPTION INTERVENTIONS

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Patients Initials: Date: Students Name: Catherine Harman 12

Medication Reference Sheet (one per patient)Pharmacological Therapies (Physiological Integrity)

Drug Classification Uses RecommendedDosage and

Routes

Possible Side Effects Contraindications Interactions

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Patients Initials: Date: Students Name: Catherine Harman 13

REFERENCES:

Skidmore-Roth, L. (Ed.).Mosbys Drug Guide for Nurses. (2011Missouri: ELSEVIER Mosby

MOSBYS DICTIONARY OF MEDICINE, NURSING & HEALTH PROFESSIONS. (2009).Missouri: ELSEVIER Mosby

Kockrow, E.O., & Christensen, B.L. (2011). Foundations in Adult Health Nursing. Missouri: ELSEVIER Mosby. Pages:

Edmunds, M. W. (2010). Introduction to Clinical Pharmacology. Missouri: ELSEVIER Mosby. Pages: