Clinical Patient Preparation Worksheet

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Chamberlain College of Nursing Clinical Patient Preparation Worksheet NR324/NR325 Student: Joycelyn Arnett Date of care: 7/29/2013__________________ Client Initials:____D.A.______Age__48_______ Gender ____Male____ Race/Ethnicity: ___African American____ Allergies: NKDA____________________________________________________________________________________________________ Social History:no smoking or recreational drugs_______________________________________________________________ Pertinent Past medical History: hypertension__________________________________________________________________ Chief Complaint&date: Abdominal pain_________________________________________________________________________ Primary medical diagnosis: Perforated…show more content…
| B = Background | Past Medical History: Home Med List: | A = Assessment | Vital Signs:T: 98.6 P: 88 R:22B/P:115/6802 Sat:100 | Respirations:Rate:22Normal Breath Sounds: NormalTreatments/02:NA | Cardiovascular:HR:88Rhythm: Normal | Neurology:Alert: OX3Verbal: normalPainful: NAUnresponsive: no | Pain Current:0 1 2 3 4 5 6 7 8 9 10Patient’s Pain Goal: Zero | GI/GU: normalLast BM:7/29/13 | Diet:Fluid Restriction:NAI_______/O________Weight: 224LBS | Integumentary:Mattress:NABraden Scale:NAWound Care: n/a | Tubes/Drains: n/a | Medications given this shift:TYLENOL,phenegranMorphine,zofranMedication Patch:NADate Applied:NA

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