NUR 3241- Adult Health Nursing I

PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week:

Dates of Care:

Patient Demographics, Health History and Admission History

Patie
nt

Se
x

Ag
e

Roo
m

Admitti
ng Date

Attending Physician/Treatment
Team:

Admitting Chief Complaint:

Consultants seen during this hospitalization:

Present Diagnosis:

ER Management:

Allergies:

Code Status:

Isolation Status:

Admission Height:

Admission Weight:

Arm Band Status:

Communication needs:
Past Medical History:

Significant events during this hospitalization:

Tests, treatments and interventions impacting clinical days care:

Advance Directives/Ethical considerations: (DPOA, Hospice, DNR, Living Will,

etc..)

Health Assessments
Vital Signs: (2 sets per day)

Pain Assessments and Interventions:

Time
T
P
R
B/P
Pulse Ox
Pain
Score
Time
T
P
R
B/P
Pulse Ox
Pain
Score
Respiratory Assessment and
Intervention:

Neurosensory Assessments and

Interventions:

Cardiovascular Assessments and

Interventions:

Musculoskeletal Assessments and

Interventions:

Renal Assessments and

Interventions:

Skin and Integument Assessments and

Interventions:

Gastrointestinal Assessment and

Intervention:

Endocrine Assessment and Intervention:

Reproductive Assessment and

Intervention:

Vascular Access Assessment and

intervention:

Safety Assessment and Intervention:

Post-operative/Post-procedural Assessment
and Intervention:

Psychosocial Assessment and Interventions:

Cultural/Spiritual Assessment and Interventions:

Growth & Development Assessment and intervention:

Pertinent Diagnostic Data

Diagnostic
Data
WBC
RBC
HGB
HCT
Platelets

Results

Normal Lab
Values

Significance within your patient

Results

Normal Lab

Significance within your patient

PT
INR
PTT
Cholesterol
Glucose
BUN
Creatinine
Sodium
Potassium
Chloride
Calcium
T Protein
Albumin
SGOT
SGPT
Alk Phos
Magnesium
Amylase
Lipase
eGFR
CK
CK-MB
Troponin I
Myoglobin
LDI

Diagnostic

Data
Urinalysis
Color
Character
Spec. Grav.
pH
Protein
Glucose
Blood
Nitrites
RBC
WBC

Values

Urine Culture
Chest X-ray
MRI
CT Scan
Other tests:

Pharmacological Intervention
Medication

Dose, Route
and
Frequenc
y

Classificati
on

Purpose/Mecha
nism of
Action

Significant Side
Effects /
Adverse
Reactions

Nursing
Implic
ations

Current Plan of Care: (A short statement that summarizes the anticipated plan of
care)

Discharge Plan:

Teaching Needs:

Pathophysiological Discussion
7

Discuss the current disease process at the cellular level (in your own
words).
Explain why this patient is encountering this particular health deficit.
Describe the relationship of this current health alteration to co-morbid
medical conditions?
Describe the disease process: etiology, epidemiology, pathophysiologic
mechanism, clinical manifestations and medical and surgical
management of the alterations.
Identify common complications that may occur with the alterations or
treatment modalities.
What is the patients overall prognosis.
Include appropriate references and use APA format.

Nursing Diagnoses
List the top 5 nursing diagnoses for this patient. Use NANDA format (diagnosis,
related to, as evidenced by) and place the diagnoses in their priority order. Briefly
discuss the rationale for this priority order.
Priorit
y
1

Nursing Diagnosis

Related to

As Evidence By

Rationale

Nursing Management and Intervention

Select the two highest priority nursing diagnoses and complete the following table.
Nursing Diagnosis:
Assessment or data
collection
relative to
the nursing
diagnosis

Patient Goals

Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)

Interventions/

Evaluation

Implementations

Nursing Diagnosis:
Assessment or data
collection
relative to
the nursing
diagnosis

Patient Goals

Patient Outcome
(objective,
expected or
desired
outcomes, or
evaluation
parameters)

Interventions/

Evaluation

Implementations

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GUIDE TO THE
PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET
One of the most important aspects of nursing is assessment because nursing assessment provides the data upon which decisions related
to the management of health alterations are made. Students will rely on their knowledge from the health assessment course to
complete the worksheet. Reference to the Health Assessment text is essential. This guide has been developed to prompt the student in
recording their observations and assessments; it is not intended to be exhaustive. Student will complete the assessment and enter the
data which is pertinent regardless of the prompts in this guide.
Item being assessed

Data to consider and record

Patient
Chief Complaint

Record the patients initials. Remember HIPAA rules.

Record the reason for admission. What symptoms or alterations
led the patient to seek care?
Identify the chief physician caring for the patient. Identify the
service team if appropriate.
Patients often are admitted due to a symptom or alteration and a
diagnostic workup occurs. This cell is used to record the
current actual diagnoses.
If the patient is admitted following a brief ER visit, record any
pertinent care or treatment completed in the ER.
Identify the type of isolation used while you cared for the
patient.
Identify the color code and rationale for any arm bands.
Identify unique communication needs of the patient. Think of
usual language spoken, verbal and nonverbal communication
styles, and any barriers to communication. Osborn (pg 258
262) is a good resource.
Identify pertinent health issues in the patients past & how each

Attending Physicians/
Treatment Team
Present Diagnosis
ER Management
Isolation Status
Arm Band Status
Communication Needs

Health History

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Significant Events

Scheduled Tests or
Interventions
Pain Assessments

Respiratory
Assessments

has been managed. Osborn (Ch 9) is a good resource.

Identify any event or issue which has happened during this
hospitalization which may have had an impact of the patients
current health state. Specify date, event and outcome of the
event.
Identify any tests, interventions which were scheduled or
performed on this clinical day.
Identify the pain scale used. Describe the location, duration,
intensity and character or the pain as well as what exacerbates it
and relieves it. Identify all interventions employed and the
outcome from it. Osborn (pg 339) is a good resource.
Identify the respiratory system assessments completed. Include
all oxygen modalities being used and any respiratory
interventions applied (e.g., suction, respiratory therapy,
tracheostomy care, chest tubes and location). Be sure to include
any pertinent lab or diagnostic tests for this system.

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Neurosensory
Assessments

Cardiovascular
Assessments

Musculoskeletal
Assessments

Renal Assessments

Skin and Integument

Assessments
Gastrointestinal

Identify the neurosensory system assessments completed. Of

there are alterations in the system, be sure to specifically speak
to
LOC, orientation, cooperation, and ability to follows
commands. Speech ability, Glascow Coma scale, headaches,
tremors, weakness, numbness and paralysis are all included as
well. Be sure to include any pertinent lab or diagnostic tests for
this system.
Identify the cardiovascular system assessment completed.
Specifically speak to the presence of telemetry monitoring and
pattern if in use. If the patient has a pacemaker/IAD it should
be noted here. DVT prevention activities should be included.
Be sure to include any pertinent lab or diagnostic tests for this
system.
Include the musculoskeletal system assessments completed.
Specifically include the patients activity orders for the day,
their actual activity level and tolerance. If there are any
supportive or restrictive devices in use, record those. Be sure to
include any pertinent lab or diagnostic tests for this system.
Osborn (p. 1796) may be a good resource for this section.
Include the renal system assessments completed. Specifically
include the patients usual voiding patterns and any deviation
from the usual. If there are any renal support systems in use
(e.g., catheter, CBI dialysis), identify them. Be sure to include
any pertinent lab or diagnostic tests for this system.
Include the integumentary system assessments. Be sure to
address the Braden Score. Include wound assessments and
interventions. Pertinent lab or diagnostic tests for this system
must be stated.
Include gastrointestinal system assessments. Be sure to identify

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Assessment

Cultural and Spiritual

Assessment

the diet prescription that is ordered and the nutritional intake

while you are on duty. Special concerns (e.g., swallowing
interruptions) or interventions (e.g., nutritional supplements)
should be addressed. Pertinent lab or diagnostic tests for the
system should be included.
Include endocrine related assessments that have not been
reported above. Be sure to identify the blood glucose results for
the day in relation to the typical pattern for the patient.
Pertinent lab or diagnostic tests for the system should be
included.
Include the gender specific reproductive system assessments.
For the female include: gravida/para status, LMP, breast exam,
and most recent gyne exam. For the male include: BPH
symptoms, and most recent prostate exam.
Include information about the type of access device, location,
date inserted, type of dressing, type of fluid and flow rates. The
tubing status and change dates should also be addressed.
Include information of the assessment and interventions as
related to environmental safety. Address items such as position
of the bed rails, use of bed alarms and assistive devices in use.
The daily fall risk assessment should be discussed. Restraints,
if used, should be reported including the type, duration & reason
for use.
As appropriate address elements such as mental illness, social
history, living arrangements, primary care giver, substance
abuse, maternal/infant bonding and family dynamics.
Include religious preference, adaptations & modifications and
end of life decisions. Osborn (Ch 9) is a good resource.

Growth and

Describe what stage of development is evident with this patient.

Endocrine Assessment

Reproductive
Assessment
Vascular Access
Assessment
Safety Assessments

Psychosocial
Assessment

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Development
Assessment

Include physical, psychosocial, cognitive, moral and spiritual

development using various theorists. Osborn (Ch 13) is a good
resource.

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