NURS 4045 Adult Health Competencies II

Texas Woman's University

Patient Data Sheet
Student's name: __________________
Date of Care: __________
Pt. location/Unit: ___________
Pt. initials: ________
Age: _______
Gender: __________
Ethnicity: _______________________
ALLERGIES:____________________________________________________CODE STATUS:____________________
Medical Diagnosis: ________________________________________________________________________________
Date of Admission & Course of present hospitalization:______________________________________________
________________________________________________________________________________________________
Past Medical/Surg.history:_________________________________________________________________________
________________________________________________________________________________________________
Social history: ____________________________________________________________________________________
Family interaction/relationship: _____________________________________________________________________
Communication with patient: _______________________________________________________________________
Isolation: Yes __ No__ Type: _____________________________ Why: _____________________________________
Oxygen Delivery: Room air:________ Nasal cannula: _________Facemask: ______ Other: ____________________
Ventilator settings: TV: _____ FIO2: ____ Mode:_______ rate/total: ___/___ PEEP: ____ PS: _____CPAP: _______
Nutrition: Diet: ______________ Feeding tube(type and location): ____________________ TPN or PPN: _____________
Chest tubes: ________________________ Drains: ________________ NGT: __________________ Foley: _______
Invasive lines/monitoring: (include location) Arterial line:______________ PA catheter _____________ IABP:___
Central line(s):_______________ Peripheral IV(s):_________________________________ ICP monitor: __________
IV Infusions (dosage--include mcg/kg/min, mg/hr, units/min or other format as appropriate (look at the order)
PATIENT WT: ___________
Drug
infusion

Current
IV rate

Current
dose

Page 1 of 11 Patient data sheet page

IV site location
(where is it
running?)

Drug concentration (How is

bag mixed)

revised 10/14/16

Why is THIS patient

getting this infusion?

NURS 4045 Adult Health Competencies II

Patient Data Sheet- Assessment

Data

Neuro: ICP _____ CPP_____ GCS_____Sedation Assessment (RASS score)_______________________________

_________________________________________________________________________________________________
Musculoskeletal: __________________________________________________________________________________
Cardiovascular: HR____ BP_____ABP_____ CO/CI________ PAP/PAWP ______ CVP_____ SpO2_____________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Respiratory: Oxygen/Ventilator settings________________________________________ RR______
___________
_________________________________________________________________________________________________
GI: ______________________________________________________________________________________________
_________________________________________________________________________________________________
Renal: 24 hour I/O________ _________________________________________________________________________
_________________________________________________________________________________________________
Integumentary: T:______ F or C _____________________________________________________________________
_________________________________________________________________________________________________
Pain Assessment: _________________________________________________________________________________
Delirium Assessment:______________________________________________________________________________
Psychosocial issues:______________________________________________________________________________
Other:___________________________________________________________________________________________
o

ECG strip:
Lead: ______ Atrial/ventricular rate: ______ Regular/irregular: _______ PR interval: _____ QRS interval: _______

ECG interpretation: ___________________________ ECG Intervention:___________________________

(attach the ECG strip you analyzed above, here. Staple or tape it in place. NO NAMES or other identifying information left on strip.)

Page 2 of 11 Patient data sheet page

revised 10/14/16

LIST ALL VALUES that are pertinent to this patients situation. Provided all values highlighted please.

Lab

Normals

Results/Date

WBC

7.2

RBC

4.77

PLT

280

PT/I
NR
PTT

N/A

HgB

13.8

Hct

37.9

Na

131

5.4

Cl

102

Osmolality

N/A

BUN

17

Creatinine

1.91

Glucose

75

Albumin

N/A

Ca (Serum or Ionized?)

9.6

Mg

1.2

CK

N/A

CK-MB

N/A

Rationale and/or importance for this patient

N/A

CRP

0-0.5

4.69

Troponin

0-0.03

0.03

Arterial : pH

N/A

N/A

PaCO2

N/A

N/A

PaO2

N/A

N/A

HCO3

N/A

N/A

BE

N/A

N/A

Ventilator settings
for the blood gas
Urinary: pH

This is required for blood gases.

5-8

6.0

Specific gravity

1.001-1.035

1.015

sodium

N/A

N/A

osmolality

N/A

N/A

Creat. clearance

N/A

N/A

GFR

32

Protein, urine

0-14

12

Amylase and
Lipase

N/A

N/A

Page 3 of 11 Patient data sheet page

revised 10/14/16

Liver
transaminases
Uric acid

N/A

N/A

2.5-8

6.8

Lipid profile
Cholesterol
Triglyceride
HDL
LDL
Hemoglobin A1C

<200
<150
>=60
<100
4.3-6.1

210
183
33
140
5.3

Vitamin B12

213-816

580

Folate

>=7

13.2

TSH

0.35-4.94

0.01

Free T4

0.7-1.48

1.08

PTH

15-90

74.4

ANA

Negative

Negative

Ds DNA Ab

Negative

Negative

C3 complement

82-193

144

C4 complement

15-57

41

Hepatitis B surface
Ag
Hepatitis C Ab

Nonreactiv
e
Nonreactiv
e

Nonreactive

Date

Nonreactive

Positive Culture Reports?

Site

Result

Additional Notes/ Comments:

10/13/16 MR orbit face neck without IV contrast: Long segment right cervical level
vertebral artery vasculopathy and flow compromise
10/13/16 MR neck without IV contrast: No visible flow right vertebral artery,
chronicity and specific etiology unknown.
10/13/16 MR head without IV contrast: No visible right vertebral artery flow.
Otherwise negative MRA head
08/05/15 Protein electrophoresis: Gamma globulins increased in a diffuse fashion.
This indicates a chronic immune or inflammatory
response._____________________________________________________________
_08/05/15 Urine electrophoresis: Urine electrophoresis shows no evidence of
monclonal proteins or free light
chains________________________________________________________________
_04/15/15 DEXA Bone Density
These findings are consistent with a normal BMD of the lumbar spine
Page 4 of 11 Patient data sheet page

revised 10/14/16

and bilateral femoral necks. There is no increased risk of an

osteoporotic fracture as compared to the young adult population__]
_05/01/15 _Ultrasound right breast_____
There is no sonographic evidence of malignancy.
The 5 mm oval cyst in the right breast is benign. A 1 year screening mammogram
is
recommended_________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________

Page 5 of 11 Patient data sheet page

revised 10/14/16

Scheduled Medications-Include all IV Medications. Infusions are listed on first page.

Medication
Time
Dose Frequency Route Why Patient is
Major Side Effects
Name
getting
(must have)
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

Page 6 of 11 Patient data sheet page

revised 10/14/16

Medication
Name

Time
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100
0600
0700
0800
0900
1000
1100

Dose Frequency Route Why Patient is

getting

Major Side Effects

(must have)

1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700
1200
1300
1400
1500
1600
1700

Page 7 of 11 Patient data sheet page

revised 10/14/16

PRN Medications
Medication
Dosag
e

Frequenc
y

Page 8 of 11 Patient data sheet page

Rout
e

Why patient is
getting.

Major Side Effects

revised 10/14/16

Problem list
List 5-10 problems, ranking them in order of importance. The most important items become
your care plan focus.
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.

Page 9 of 11 Patient data sheet page

revised 10/14/16

NURS 4045 Adult Health Competencies II

Patient Data Sheet Patient Care Plan
Primary Nursing Diagnosis (1) with related information and evidence:

Secondary Nursing Diagnosis (2) with related information and evidence:

Intervention(s) and Evaluation(s):

Diagnosi
s#

Interventions (What did you do?)

Page 10 of 11 Patient data sheet page

Evaluation (How did it work)

revised 10/14/16

Diagnosi
s#

Interventions (What did you do?)

Page 11 of 11 Patient data sheet page

Evaluation (How did it work)

revised 10/14/16