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Weekly Patient Care Worksheet0

This document contains a weekly patient care worksheet for assessing a patient and documenting key information. It includes sections to document biographical data, activities of daily living, intake and output, vital signs, laboratory results, a full systems assessment, nursing diagnosis, goals and interventions. The worksheet is designed to help the nurse comprehensively evaluate the patient and their condition, identify problems within the nursing scope, develop a targeted nursing diagnosis and care plan to address the identified problems.

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mitchelltaiwo007
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162 views

Weekly Patient Care Worksheet0

This document contains a weekly patient care worksheet for assessing a patient and documenting key information. It includes sections to document biographical data, activities of daily living, intake and output, vital signs, laboratory results, a full systems assessment, nursing diagnosis, goals and interventions. The worksheet is designed to help the nurse comprehensively evaluate the patient and their condition, identify problems within the nursing scope, develop a targeted nursing diagnosis and care plan to address the identified problems.

Uploaded by

mitchelltaiwo007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Weekly Patient Care Worksheet


(Assessment & Critical Thinking) Name___________________
Date_________________

Biographical Data
Age: Code Status:
Sex:
Weight:
Allergies: Smoker: (or Hx of smoking) ppd:
Diagnosis (Medical/Surgical):
Type of Surgery: Date of Surgery:
Relevant Health History:
Primary diagnosis:
Diagnostic Procedures _Date_Results

ADL’s
Diet and Feeding status:
Mobility status including aids:
Toileting:
Other:
Intake and Output Risk Factors: (Social, developmental,
Oral: NG: financial, other)
IV:
Urine (characteristics):
Blood loss (amt & site):
Other:
Last BM (characteristics):
Medications
Name _ Desired Action_Major Side Effects

Laboratory Results_and their Significance

Vital Signs (include qualities prn) Mental Status


T Pulse LOC: Oriented: /3
Respirations BP Behavior(s):
O2 Sat
Pain: /10 Cognition:
Thought process:
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Systems Assessment (IPPA_Complete as appropriate to your client)


Integumentary Respiratory

Colour: Temp: Moisture: Rate: Rhythm: depth:


Turgor:
Edema: (type & location) Quality: (Laboured/unlaboured)
Pressure Points skin condition:
Cough & sputum: (describe)
Lesions: (ABCDE)
Chest shape:
Ecchymosis/Abrasions/Contusions:
Use of accessory muscles:
Open area(s):
Characteristics: (size & depth) Pain: /10

Drainage (type & amt): Breath Sounds (describe):


Undermining/Tunneling:
Edema Adventitious Sounds (location & describe)
Healing by:
primary Secondary Tertiary

Cardiovascular Peripheral Vascular & lymph

HR: Rhythm: Strength: Peripheral Pulses: (rhythm, strength bilaterally)


BP: (radial, brachial, poplitea, dorsalis pedis, femoral,
Auscultory gap: posterior tibial)
Pulse deficit:
Edema: (location & describe)
Skin Colour:
Cap Refill:
Skin colour, Temp (extremities):
S1S2 heard:
Extra heart Sounds:
Nails:
Jugular vein distention:
Lymphnodes: (head & neck, axillary,
epitrochlear, inguinal)
Neurological Abdominal

Paresis (location) : BM (describe & frequency)


Plegia (hemi, para, localized) Diet intolerances:
CSM (colour, sensation, movement)
Shape & Contour:
Pain: /10 Bowel Sounds:
Grip Strength: (equal bilaterally)
Muscle strength: (describe) Masses, bulges:
Balance: (walking) Pain/tenderness:
Coordination: Liver span:
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Nursing Process and Critical Thinking


In your own words identify the holistic patient problems that are within the realm of the
nursing role (ie) a response to disease, illness or client situation.
1.

2.

3.

Choose one of these “Patient problems” and cluster your Assessment Data:
(List the assessment data that supports your patient problem)

Objective Data:

Subjective Data:

Nursing Diagnosis
Identify a 2 or 3 part (as appropriate) Nursing Diagnosis appropriate to your “patient
problem”.

Client Goals & Evaluation Criteria

Client Goals Evaluation Criteria

Nursing Interventions
A. Based on the Nursing Diagnosis above list what did you do for this client
(include any client teaching).

B. Upon reflection and in consideration of additional evidence based resources list


other interventions you might include in the future.

An Example of where I used Critical Thinking or problem Solving this week was:
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