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CAT Date:________ PATIENT INITIALS__________
Student______________________
Code PMH / SH
Adv. Dir.
Allergies Admit Date/ Diagnosis
Neuro
Day One:
Day Two:
Cardiac
Day One:
Day Two:
Resp.
Day One:
Day Two:
GI
Day One:
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Day Two:
Pain
Day One:
Day Two:
Psych/So
c
Day One:
Day Two:
ADLs
Day One:
Day Two:
IV Site Day One:
Day Two:
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GLUCOSE 60-110 mg/dL
NA 135-145 mEq/L
K 3.5-5.0 mEq/L
CL 97-107 mEq/L
CO2 25-26 mmol/LBUN 5-20 mg/dL
CR 0.5-1.1 mg/dL
CA 8.2-10.2 mg/dL
MG 1.6-2.6 mg/dL
Mg - MCH 5-8 mg/dL
PHOS. 2.5-4.5 mg/dL
ALBUMIN 3.4-4.8 g/dL
PH 7.35-7.45
PO2 85-100mmHg
PCO2 35-45 mmHg
LACTATE 0.4-0.8 mmol/L
HCO3 17-24 mEq/L
PT 10-13 secs
PTT 30-45 secs
INR 2.0-3.0 therapeutic
CK 26-174 U/L
CK MB < 6% CK
TROPONIN
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Concerns: What do you think is causing the abnormal value? Do
not fill in every
cause, just the ones pertinent to your client.
How do the lab values relate to your physical
assessment/diagnoses and/or the
medical diagnoses?
What complications do you anticipate and did you assess for
those symptoms?
Are there any labs you want to discuss with the provider or
request an order for?
Why?
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Define Primary Health Problem (Medical Diagnosis)
Primary Medical/Admitting Diagnosis:
Related Surgical Procedure (Date):
Pathophysiology (how normal anatomy and physiology is altered by
the patients disease/problem):
Etiology (cause of the disease):
Expected Signs and Symptoms (circle those exhibited by your
patient):
Typical Nursing Management (include the range of treatment
options for this problem and circle those that apply to your
patient):
Typical Medical Management (include the range of treatment
options for this problem and circle those that apply to your
patient):
Textbook References and resources (include title and page
number):
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Scheduled MedicationsName (Generic
and Brand)Classification
(therapeutic andpharmacological)
Current
Medication
Order (dose,
route, frequency)
Recommended
Route and
Dosage
&Max Daily dose
Indication:
Why is thispatient receiving
this medication?
Action &
Therapeutic
Effects
Pharmacokinetics
Metabolism
and Excretion
onset, peak,duration
(insulin and IV
meds)
Half life
Reversal agent(if applicable)
Adverse/Side
Effects
(major/life
threatening in boldtype and most
commonly
occurring in bluetype)
Key Nursing
Implications:
*Administration
parameters,food/drug
interactions
*Implementationand Assessment
* Education* Relevant lab data
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PRN medicationsName (Generic
and Brand)
Classification
(therapeutic and
pharmacological)
CurrentMedication
Order (dose,
route, frequency)
Recommended
Route and
Dosage
&
Max Daily dose
Indication:
Why is thispatient receiving
this medication?
Action &
Therapeutic
Effects
Pharmacokinetics
Metabolismand Excretion
onset, peak,
duration(insulin and IV
meds)
Half life
Reversal agent
(if applicable)
Adverse/Side
Effects
(major/life
threatening in bold
type and most
commonlyoccurring in bluetype)
Key Nursing
Implications:
*Administration
parameters,
food/drug
interactions*Implementationand Assessment
* Education* Relevant lab data
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NURSING DIAGNOSIS:
GOAL (long term goal):
OUTCOME (short term goal):
NURSING INTERVENTIONS PATIENT RESPONSES
Assess:
Monitor:
Action:
Administer:
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GOAL (long term goal):
OUTCOME (short term goal):
NURSING INTERVENTIONS PATIENT RESPONSES
Assess:
Monitor:
Action:
Administer:
Collaborate:
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OUTCOME (short term goal):
NURSING INTERVENTIONS PATIENT RESPONSES
Assess:
Monitor:
Action:
Administer:
Collaborate:
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NURSING INTERVENTIONS PATIENT RESPONSES
Assess:
Monitor:
Action:
Administer:
Collaborate:
Educate:
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