CARE PLAN WORKSHEET
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Student’s Name: |
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Date/Time: |
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Client’s Initials: |
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Admission Date: |
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Age: |
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Sex: |
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Race: |
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Religion: |
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Allergies: |
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Diet: |
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Activity: |
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Admitting Medical Diagnosis: |
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Past Medical History: |
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Past Surgical History: |
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History of Present Illness: |
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Client Understanding of Illness: |
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PATHOPHYSIOLOGY |
What Medications are you currently taking at home?
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MEDICATION |
TIME(S) |
WHY? |
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Are your medications causing you any discomfort? |
OVERVIEW MEDICATION(S) WORKSHEET (TOPICAL, PO, IM, SQ, IV)
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NAME/CLASSIFICATION |
DOSE/ROUTEFREQUENCY SAFE RANGE |
MECHANISM OF ACTION |
INDICATIONS |
SIDE EFFECTS |
NURSING CONSIDERATIONS AND PATIENT EDUCATION |
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Chemistry |
Normal Values |
Date |
Date |
Hematology |
Normal Values |
Date |
Date |
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Na |
WBC |
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K |
RBC |
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Cl |
Hgb |
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CO2 |
Hct |
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Ca |
MCV |
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Glucose |
MCH |
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BUN |
MCHC |
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Creatinine |
Platelets |
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Phosphorus |
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Cholesterol |
DIFFERENTIAL |
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Total Protein |
Neutrophils |
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Albumin |
Bands |
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Alb/Glob Ratio |
Lymphocytes |
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AST (SGOT) |
Monocytes |
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ALT (SGPT) |
Eosinophils |
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Total Bilirubin |
Basophils |
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Amylase |
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Lipase |
COAGULATION |
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LIPID PROFILE |
PT |
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Total Cholesterol |
INR |
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Triglycerides |
PTT |
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HDL |
Bleeding Time |
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LDL |
Fibrinogen |
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Chol/HDL Ratio |
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GGT |
OTHER LABS:
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Labs |
Normal Values |
Date |
Date |
Labs |
Normal Values |
Date |
Date |
Relate the clinical significance of abnormal lab values above:
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Abnormal Lab Value |
Explain why lab value is abnormal |
DIAGNOSTIC PROCEDURES
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Diagnostic Procedure |
Report |
NURSING CARE PLAN
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Assessment Subjective/Objective Date |
Priority Nursing DX/Clinical Problem |
Client Goals/Desired Outcomes/ Objectives |
Nursing Interventions/Actions/Orders and Rationale |
Evaluation |
