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ST. JOSEPH’S COLLEGE OF MAINE

DEPARTMENT OF NURSING
NU 301 Patient Care Worksheet

Student Name: Date:

Instructor/Unit:

All information must be kept HIPAA compliant

Room number: Patient initials: Age: Gender:
Admission date: Code status: Precautions:
Admission Diagnosis:
Surgical Procedure:
Allergies (include reaction):

1.) History of admit information: The reason the patient came into the hospital and pertinent facts related to
diagnosis. BE SPECIFIC. Describe how the patient looked upon arrival to hospital, before the diagnostic scans
and the MD diagnosis.

2.) Past Medical History:

3.) Pathophysiology: Briefly describe the pathophysiology of primary diagnosis and ONE other medical problems in the
patient’s history. State two potential complications of each disease process.

Primary diagnosis:

Complications:
a.
b.
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Diagnosis:

Complications:
a.
b.

4.) Procedures: Surgical and other invasive procedures done during this admission. Please define and describe rationale
for surgery/procedures.

5.) Recent diagnostic tests and procedures: CT, XRAY, MRI etc. Include dates and results.

6.) Discharge Plan/Needs: Where will this patient go after discharge? Are there any anticipated needs for care/services,
spiritual needs, and educational needs. Remember that discharge planning begins on admission.
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7.) List 5 Medications that your patient is on, these should include those that you are unfamiliar with: including IV,
IM, PO, SC, and PRN. For continuous IV drips include dosage (units/hr, mg/hr, mcg/kg/min, etc.) and rate (ml/hr)

Drug (trade and Dose, Route, Mechanism Major Side Reason For Nursing
generic names) Frequency, Safe Of Action Effects/Food Drug Use In This Considerations
& Drug Class Dosage Ranges Interactions Particular
Patient

List Other Medications and details of administration:

i.e. Tums PO QID PRN for Indigestion or Docusate 100mg 1 capsule PO BID
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8. Lab Results: Note abnormal values and state why this lab value is abnormal specific to your patient. Note trends in lab
values. Add any additional labs tests that are pertinent to the care of your patient.
Lab Study Normal Date Date Date Purpose Of Lab Reason For Abnormal
in THIS PARTICULAR
PATIENT
70 -119
Glucose

Sodium 136-145

3.5-5.0
Potassium

Chloride 98-112

CO2 22-31

7-21mg/dl
BUN

0.5-1.4mg/dl
Creatinine

1.6 – 2.1
Magnesium

Calcium 8.9-10.3

Albumin 3.5-5.0
4-6
RBC
4.8-10.8
WBC

HgB 12.0-16.0

Hct 37%-47%

Platelets 140K-440K
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20-25
PTT seconds

0.9-1.1 =
INR WNL
2-3 =
therapreutic
2.5-3.5 =
high-dose
warfarin

Date Date Date


9. *Interventions /time /time / time Describe Parameters
DRO: MRSA_____ VRE_____ Contact_____
*Precautions Fall Risk:______ Nephro/breast: Left____
(what type ?) Right____
*Baseline Vital Signs VS: Temp____ HR_____ RR_____ BP_____
(on admission) Sat___
Vital Signs Q4h
Doppler/Palpable: Right: PT___DP_____Left:
Pedal Pulse Checks PT____ DP_____
Neuro Checks
Glucose checks
Freq:_______ Scan: Scan: Scan:
*Pulse oximetry (%):
Oxygen:
LPM____/RA
CPT (chest percussion
therapy) Freq:______
Incentive Spirometer
Freq:______
Foley Catheter Catheter care completed: Yes / No

*Diet orders Type:__________________________

*Last BM
Colostomy/ileostomy Stoma: Stoma: Stoma: Output: Care:
Nasogastric tube:
Suction/Gravity Output: Time____ Amt_____Replaced_____
(circle) Time____ Amt_____Replaced_(ml/ml)
Tube feedings (NG, Type of tube:
JT, GT) Type? Rate? Residual: Residual: Residual: What is infusing: rate/hr:
Drains – Constavac,
JP Output: Output: Output:
Type: Location:
Central Line(s): Last dressing change: Infusing:
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*Saline Lock Location

VIPAS What’s infusing? Discontinued:
*Intake and output I: I: I:
maintained O: O: O:
Fluid Restriction

Weight (Daily):
Dressing Change Type:
Epidural/PCA: What
type? What rate? PCA: Drug______Setting____/____/____
Epidural: Drug:_____Conc._____Rate/hr____
*Activity level (what
is ordered): Comment:
TED Hose
Compression
Stockings
Other:
(restraints/special
bed/special
treatments)

10. Clinical Assessment Findings:

Neurological: Level of orientation, behavior, movement, sensation quality of speech, level of consciousness, swallowing
reflex.
Pupil Size:
Right: 2mm 3mm 4mm 5mm Normal Brisk Sluggish
Left: 2mm 3mm 4mm 5mm Normal Brisk Sluggish
Droop: Left Right NONE Drift: Left Right NONE
Swallow: Intact Difficult__________________________________
Memory Recall:
Speech Quality
Visual deficits
Photosensitivity: Neglect: Aphasia(describe) Posturing:
Note:
Mental Status: Will include level of consciousness and level of orientation.
General: Anesthetized Awake/Alert Comatose
Oriented: To person To person and place To person, place, and time
Disoriented: describe be specific give examples:

GCS:
Eye Opening: 4. Purposeful/spontaneous 3. To voice 2. To pain 1. None
Verbal: 5. Oriented 4. Disoriented 3. Inappropriate words 2. Nonverbal/sounds only 1. None
Motor: 6. Obeys commands 5. Localizes pain 4. Withdrawal 3. Flexion 2. Extension 1. None
Total Score:
CAM Score:
Mobility/Strength: Moves against resistance Moves above gravity
Minimal movement Immobile
Grasps: Strong Weak Equal Leg strength: L: 1 2 3 4 5
Hand strength: L: 1 2 3 4 5 R: 1 2 3 4 5 R: 1 2 3 4 5
Note:
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Cardiovascular:
AP heart rate for 60 seconds: ____________ Drugs affecting HR _____________________
B/P: ____________ Orthostatic changes: Yes _____ No _____
Drugs affecting B/P: _____________________________________________________________
IV fluids (rate, type, site): _____________________________________________________________
Telemetry Yes NO
Note:

Respiratory: Will include rate, regularity, depth and ease of respirations; lung sounds; cough; amount, color, odor, and
consistency of sputum or nasal drainage.
Respiratory rate:
Respiratory quality: Deep Shallow Unlabored Labored Symmetrical Asymmetrical
Breath sounds right: Breath sounds left:
Cough present: Color, consistency, and amount of sputum:
Oxygen therapy: 02 Sat:
Incentive spirometry use:
Pulmonary Medications: Effect:
Pulmonary Toilet:
Chest Tube R/L: Settings: cm LCS/H2O seal
Drainage (amt and consistency):
Tracheostomy: size: Brand: Green card? Suctioned No Trach care provided N/A
Note:
Pain: Will include patient description: type, location, duration, radiation, and intensity on appropriate pain scale;
precipitating factor, and alleviating factors.
Pre and post pain scale for every time med administered:
Time: Med: Dose: Pre: Post:
Time: Med: Dose: Pre: Post:
Time: Med: Dose: Pre: Post:
PCA/Epidural Settings: ___mg/____min/____mg in 4 hour lockout
Note:
Gastrointestinal/Nutrition: Will include abdominal appearance; bowel sounds; palpation; diet tolerance; presence of
nausea or vomiting, pattern of bowel movements.
Bowel sounds: None Hypoactive Active Hyperactive
Abdomen: DistendedNon-distended Tenderness: Yes No
Last stool (amount/consistency):
Diet:
Glucose checks:
Presence of NG tube/feeding tube: Yes No Details:
Note:
Renal/Fluid Balance/GU: Will include amount, color and odor of urine; voiding patterns or catheter patency; bladder
distention, presence of vaginal/penile discharge or irritation.
Foley: Condom cath______ Suprapubic_____
I&O shift totals: IN: OUT: Voids: Continent Incontinent
Urine: clear cloudy straw yellow amber bloody Sediment: Yes No Last UA: Foley
care: time:________ Straight Cath_____ _____ ______
Bladder scan time/result____/____ ____/____ ____/____
Note:
Integument: Will include integrity, hygiene, skin color, condition, temperature; turgor, condition of mucous membranes;
if stoma present: stoma color, size and shape, status of peristomal skin, presence of stomal bleeding.
Braden Scale Score. Skin color: Skin temperature:
Ecchymosis:
Breakdown/pressure sore:
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Interventions: Elevated Heels DUOderm Sensicare Multipodus

Pt repositioned @:
Note:
Musculoskeletal: Will include joint swelling, tenderness; limitations in functional ROM; muscle strength and tone and
condition of surrounding tissue.

Mobility: BMAT SCORE: _________________

OOB X: _________hours To chair:_______ Ambulated:______ #assists:_____

Assistive Devices:____________
Weight bearing status:__________________ Pt repositioned @______/_______/_______
Teds: Right Left Both
Venodynes: Right Left Both CPM Machine Cryocuff
Physical Therapy:__________ Occupational Therapy:_________ Speech Therapy:___________
Note:
Neurovascular: Will include color, temperature, movement, pulses, capillary refill, edema, tenderness, presence of
ulcers, and patient description of sensation of affected extremity.

Edema: Face/neck Dependent Peripheral General Pitting # _________________

Pulses (0-3+): Left radial: _____ Right radial: _____ Left DP: _____ Right DP: _____
Left PT: _____ Right PT: _____ Left foot warm:_______ Right foot warm:_____
Pulses: palpable (p) via Doppler (d)
Note:
IV Site: Will include the observation of the insertion or exit sites of catheters (peripheral, arterial, central venous
and/or epidural) for: temperature, color and integrity of surrounding tissue; any drainage or pain and catheter
patency. VIPAS Scale assessment.
IV Lines Date inserted: VIPAS Scale:
PICC location Date dsg changed
Note:
Dressing: Will include condition of dressing, drainage on dressing; wound suction drains (if present) for patency and
drainage.
How often is dressing changed?
Drainage consistency on dressing Drains: JP drain Amount of drainage: Ventriculostomy:
Note:
Incision/Wound: Will include color, temperature and tenderness of surrounding tissue; condition of sutures, staples or
steri strips; approximation of wound edges; amount, color and odor of drainage. Incision suction drains (if present)
for patency and drainage.
VAC Size of wound Surgical
Trach: PEG: Traumatic wound

Note:
Psychosocial/ Learning: Will include knowledge of diagnosis and treatment; language, cultural, religious, psychosocial
and financial issues which impact learning; ability to comprehend; readiness to learn; learning style; barriers to learning.
Define coping mechanisms used by patient and the effectiveness.
Note:
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Nursing Care Plan

Assessment Analysis Goals for Patient What would you do for What would you need
Objective and NSG DX in PES 1 Long Term this problem as a nurse to do to evaluate
subjective data that led format 2 short term goals (actions) whether your plan
to nsg dx. worked?
Independent: Things
you can do on your own If Goal not met Why?
Dependent: requires
physician/NP order
Collaborative: Things
done with other
disciplines
Physical problem Long Term
1.

Short Term
1.

2.

Psychological Long Term

1.

Short Term
1.

2.

PCW Grade Rubric

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Possible Points Student’s Score

HPI, Pt. diagnosis accurately 10

designated, Past Hx
documented
Pathophysiology – Complete 30
and relates properly to pt. and
admit diagnosis.
Interpretation of diagnostic data 25
(including EKG, HD, ABGs, labs,
diagnostics)

Nursing Diagnosis and 25

Interventions

10
Overall completeness (all
sections filled out—including
med sheet for all meds
administered-and format, APA
references
Comments

Total 100 points per graded

worksheet