DAILY WORKSHEET
Student: _____________________________ Date: ________________________________
Client Data
Initials: ___________ Age: _____________
Room #_____________ Diet: ________________
Date of Admission: _____________________________________ Allergies: _____________________________________________
Reason for admission: __________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Patient History: _______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Diagnosis: _____________________________________________________________________________________________________________________ Surgery/Procedure: ______________________________________________________________ Vital Signs: __________________________________________________ Date:_______________________________
Blood Sugars: ___________________________________________
Diagnostic Tests
List all pertinent tests that relate to patient’s diagnosis, treatments and medications. Name of Test or Procedure Rationale for test/ procedure Normal Result Patient Result
Nursing Diagnoses (List at least 3 and prioritize for this patient)
Nursing Diagnosis 1. 2. 3. 4. Interventions Rationale
Discussion of Pathophysiology
Description of Disease (including risk factors )
Medical Diagnosis/Diagnoses: _____________________________________ Textbook Signs & Symptoms Client Signs & Symptoms
Source:
Medications
List all scheduled and PRN medications that the patient is currently taking. Relate function of this medication to the patient’s medical condition. Medication & Classification Generic/Trade Name Dose & Frequency Drug Action & Rationale Side Effects/Adverse Reactions Nursing Implications Evaluation of Effectiveness
Use another sheet if necessary
Test
Range
Date
Baseline
Date
Date
Identify WNL Significance/ Trends
(cultures, blood gases, drug levels, and other lab tests, etc)
Other Significant Lab Tests
Range
Date
Identify WNL Significance/ Trends
WBC C B C RBCs Hgb Hct Platelet C h e m i s t r i e s . Glucose Sodium
4,500-11,000/ mm3 4.2-6.1 x 106/g 11.5-17.5 g/dl 40-52% 150,000400,000 mm3 70-110 mg/dl
135-145 mEq/L Potassium 3.5-5.0 mEq/L
Chloride BUN
Creatinine
98-106 mEq/L 10-20 mg/dl 0.5-1.2 mg/dl 24-30mEq/L 1.3-2.1 mEq/L 9.0-10.5 mg/dl See lab result 11-12.5 seconds 60-70 seconds Note: Normal value range will vary depending on laboratory used.
CO2
Magnesium
Calcium C o a g INR PT PTT