NRSR 21 Patient Prep/Research Sheet

Student Name____________________________ Dates of

care______________________
2-digit
Room
Number:
Code Status: Gender: Date of
Admission:
Diet: VS Frequency: rdered Acti!ity "e!e#: $V F#uids%Rate: A##ergies:
Age Range: &'-2' 2(-)' )(-*' *(-'' '(-(' ((-+' +(-,' ,(--' -'.
Nursing /reatments%$nter!entions 0 Frequency:
1 FS2S_________________________ 1 Ambu#ate_________________ 1 Drains____________________ 1 Fo#ey________________
1 Dsg C3ange____________________ 1 C0D2 ___________________ 1 Fa## 4rec__________________
1 $nta5e 0 ut6ut________________ 1 Re6os___________________ 1 $so#ation 4rec______________
1 $ncenti!e S6irometer_____________ 1 Restraints_________________ 1 t3er____________________
4rimary Diagnosis 7inc#ude medical diagnosis8 surgica# 6rocedure%date8 or reason for 3os6ita#i9ation::
Secondary Diagnosis%t3er ;ea#t3 4rob#ems%4re!ious ;os6ita#i9ations%4re!ious Surgeries:
Cu#tura#%4syc3o-Socia# Needs:
Disc3arge 4#an%Needs:
Current 4#an of Care for 3os6ita#i9ation:
&
Laboratory & Diagnostics
Laboratory Test or
Diagnostic Exam
Reerence
Range
Date!
""""""
Res#lt
Date!
""""""
Res#lt
Date!
""""""
Res#lt
$hat do the normal and abnormal test res#lts
indicate or this patient%
&hemistry
Sodium
4otassium
C3#oride
C2
G#ucose
2<N
Creatinine
=agnesium
43os6orous
Ca#cium
"actic Acid
A#bumin
'ematology
;emog#obin
;ematocrit
R2Cs
>2Cs
Neutro63i#s
2ands%Segs
"ym63ocytes
=onocytes
?sino63i#s
2aso63i#s
4#ate#ets
4/%4//
$NR
(rinalysis
)icrobiology
&hest *+Ray
E,-
)R.
&T
2
)edical Diagnosis & )edications &oncept )ap
&oncept )ap! Corre#ations bet@een =edica# 4rimary Diagnosis8 a## Secondary Diagnoses8 4syc3o-Socia# Data 0 Co-=orbidities
Patient /ssessment
.nitial Patient/Shit /ssessment +Narrati0e o 'E/D+T1+T1E or S2STE)S /ssessment
Day 32 Signi4cant &hanges in /ssessment
)
N#rsing &are Plan
N#rsing &are Plan+ Re5#ired Elements! T6o 728 Problem Statements 7N/ND/ n#rsing diagnosis9 etiology9 & maniestations89 S+
)+/+R+T -oals 7Patient 1#tcome8 9 .nter0entions9 & 1#tcome E0al#ations: 2o# may #se the bac; o this page or an additional
page to complete yo#r patient care map:
N#rsing Progress Note
Patient<s progress to6ard n#rsing goals or response to n#rsing treatments/inter0entions
Data+/ction+Response oc#sed doc#mentation 7D+/+R8 or narrati0e style can be #sed: See Potter & Perry p: =>? @ox 2A+1
Date
/
Time
Date
/
Time
*
Student Name: Diagnosis!
Sierra &ollege /DN N#rsing Program
Pathophysiology & Standards o &are
?tio#ogy
4at3o63ysio#ogy
C#inica# =anifestations
Standards of Care
Nursing Assessments =edications
Acute $nter!entions Diagnostics
/eac3ing Needs =edica# and%or Surgica# /reatments
'
Student Name: 43armaco#ogic C#ass: ____________________________
Sierra &ollege /DN Program
)edication &ompilation
-eneric
Name
Therape#tic &lass
Sae Dose
Range
)echanism o /ction &
1nset/Pea;/D#ration
&ommon
Side EBects
N#rsing
&onsiderations
/ll Possible Rationales
or /dministering
this Dr#g
Trade
Name
Pharmacologic
&lass
(
/LLER-.ES "ist a## a##ergies in t3e a66ro6riate s6ace
=edications:
Foods:
t3er:
)ED.&/T.1NS
)edication Name Dose /
Ro#te
Times Reason Re Page
3
DAC ,-2A-2A&)