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Summary

Clinical information sheet for Medical surgical rotation...

Description

CLIENT INFORMATION SHEET (CIS) Student Name__________________________________ Patient Initials______ M

Date_______________________________

F Age______ Religion_____________ Primary Language_____________________

Allergies_____________________ DNR AD None Admission Date_____________

Height_______________

Weight___________________

Admission Diagnosis__________________________________________________

Current Diagnosis [reason for admit/chief complaint]________________________________________________________________________________________ __________________________________________________________________________________________________ Surgical/Invasive Diagnostic Procedures [this admit]____________________________________________________ Concurrent Medical History [past]____________________________________________________________________ Past Surgeries_____________________________________________________________________________________ Course of Hospitalization [what happened during stay]_____________________________________________________________________________________________ __________________________________________________________________________________________________ Precautions/Special Needs [isolation, fall, restraints]__________________Activity Order____________________ External Devices [orthopedic, SCD/IPC] __________________________________________________________ Treatments [wound care, 02] ________________________________________________________________________ Vital Signs: frequency______ BP_________T_________P________R_______ Baseline________________________ Diet_____________

Tube Feeding: type, rate/frequency, site________________________________________

Intake:

Output:

Oral________________

Urine/Foley/Incontinent/Voids________________________

Parenteral__________________________

Drainage tubes [specify]_______________

Tube Feed__________________________

Other: _____________________________ Other:

____________________________ Q 8 H or Q 12 H or Q________H

Total Input_________________

Total Output___________________

Venous Access Devices:

[type, solution, rate/saline lock, site]

BS Glucose: AM_____ PM_______

PIV______________________________________________________________________________________ CVC ____________________________________________________________________________________ Other:__________________________________________________________________________________

Pathophysiology of Medical Problem [describe etiology, progression, treatment-specific to patient]: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Consultations [type, date, results]______________________________________________________________________ Current Lab Results:

Normal

Note Additional Diagnostic Studies Below (Radiographs, Scans, etc.)

Pt. Results

Significance of Abnormals: [indicates kidney failure, anemia, etc.]

Na+ 135-145 K+ 3.5-5 Cl` 95-105 CO2 22-26 Glu 65-139 Ca2+ 8.5-10.5 BUN 8-21 Cr 0.6-1.2 Mg2+ 1.6-2.6 WBC 4.5-11 HgB 11.7-17.3 HcT 33-39 Plt 150450x109/L Bedside Glucose Other: Other: Medications: List only [complete on medication form] _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Nursing Diagnosis: [list 3 & prioritize]

Include All Nursing interventions/actions:

Anticipated Discharge Needs: [equipment; include teaching]

References [APA] Attach Additional Sheets As Necessary For Any of Above.

3

UNDERGRADUATE MEDICATION FORM

Drug, (Class, Generic/Trade Name, order Pharmacological date) Action and desired in patient (why is this Dose: patient on this Safe Range med?) Route: Time :

Reference

Side Effects/Contraindications Nursing Actions (Individualized to patient) Expected Outcome Specify how to administer the Medication...