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TRICOUNTY TECHNICAL COLLEGE NURSING 101 CLINICAL PREPARATION Pathophysiology (disease process and/or medical diagnosis) Medical Diagnoses:

Textbook signs and symptoms

Clients sign and symptoms

Chief Complaint: History of Illness: Past History: Family History: Social Data: Psychological Data: Adm.Medical Diagnoses: ASSESSMENT Subjective Data Objective Data

DIAGNOSES

Nursing Diagnosis(es):

Desired Outcome: (Goal(s)

P L Interventions A. N N I N G

Rationales

E V A L U A T I O N

Clients response to each intervention (If modifications necessary, what intervention would be appropriate?)

Was the desired outcome achieved? (Met unmet, partially met) Why?

Learning Needs/Discharge Needs

Nutritional/ Fluid Needs while hospitalized

Growth and Development Expected Developmental Actual Developmental

Physiological

Physiological

Psychosocial

Psychosocial

Diagnostic Studies: TEST NORMAL CLIENT NURSING IMPLICATIONS

Risk Factors for Medical Diagnoses:

DRUG NAME

ACTION

DOSE

SIDE EFFECTS

NURSING CONSIDERATIONS

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