Student: _________________________

Date: ___________

School of Nursing: Pathophysiology

Nursing Process Data Form

Student: ___________________________________ Date of Care: __________________
A. Identifying Data
Patient Initials: ________Age: ____ Gender: _______Allergies: ___________________
Primary Language: ______________Ethnicity: ____________ Religion:______________
Marital Status: _________________ Occupation: _________________________________
Insurance: ________________________________________________________________
Family Composition: ________________________________________________________
Home/Living Situation: ______________________________________________________
Date/s of Care: _________Date of Admission: __________Date/s of Surgery:___________
Physician(s)/Specialty: _______________________________________________________
Admitting Diagnosis/es: ______________________________________________________
Surgical Procedure(s) this hospitalization: __________________________________________________________________________
B. Biological
1. Past Medical/Surgical History/Chronic Conditions:
(Provide date of onset and/or diagnosis for each condition)
2. Recent Medical History/Reason for Admission/Course of Hospitalization:
(Discuss all related details that led to the pts. admission to the hospital up until the moment you assumed pt. care on your shift. This tells the story of current stay)
3. Home Medications: Provide name, dose, frequency and WHY the pt. needs the
medication based on their medical history & chronic conditions:

Add to table as needed. All home meds must be included.
4. Definition of Medical Diagnosis with patient’s signs & symptoms at time of admission:
5. Physical Assessment:
Ht _____ Wt______ BSA________ BMI __________

VITAL SIGNS/HEMODYNAMICS:

PAIN ASSESSMENT:

LABORATORY DATA:

ARTERIAL BLOOD GASES:

DIAGNOSTIC TEST & PROCEDURES:

(Include 12 Lead EKG, CXR, Cardiac Cath, CT, MRI, Ultrasound, Endoscopy, Echocardiogram, etc)

INTAKE AND OUTPUT Past 24º Balance ___+/-____________

Does the patient have a positive or negative fluid balance as of this date? How much?______ML

Medications

IV Solutions/Parenteral Nutrition/Blood Products :

Routine/PRN Medications

List all the patient’s medications ordered. Why would THIS patient have this medication specifically? Consider diagnosis, medical history, lab values, procedures when discussing the rational for each medication.

**Continue to copy the above chart as often as needed to include ALL Routine & PRN

meds**

Head-to-Toe Assessment

INTEGUMENTARY:

Skin: Color __________ Turgor __________ Temp __________ Moisture ___________

Lesions ________________________________________________________________

Incisions__________________________________ Dressings _____________________

Varicose Veins ______________________ Scars _____________________ Nails _____

Pressure Ulcer: Location __________________ Stage _____________ Characteristics _______________________________________________________________________

Unusual Pigmentations/Tattoos/Piercings___________________________________

Drainage/ Suction ________________________________________________________

Dressings (describe each by site, size, appearance,characteristics, drainage, etc.) ____________________________________________________________________

Note: *Labs & Medications for the integumentary system must be address here

MUSCULOSKELETAL:

Activity Level __________ROM __________Gait/Mobility __________ Posture __________

MuscleTone/Strength __________________________________________________________

Any Contractures______________________________________________________________

LUE____________ RUE_______________ LLE_________________ RLE_________________

Assistive Devices ________________________Prosthesis/es___________________________

Other Devices_________________________________________________________________

Frequent position of pt. on your shift_______________________________________________

Note: *Labs & Medications for the musculoskeletal system must be address

NEUROLOGICAL:

Level of consciousness, alertness, orientation, cognition memory (short/long term) _________________________________________________________________________

Sleep/rest patterns _________________________________________________________

Speech __________________________________________________________________

Sensory (taste, smell, touch)_________________________________________________ _________________________________________________________________________

Motor (fine/gross) __________________________________________________________

Vision ____________________________________________________________________

Hearing ___________________________________________________________________

Reflexes ____________________________________________________________________

Cranial Nerves (All must be included, how tested & results) ________________________________________________________________________

Note: *Labs & Medications for the neurological system must be address

CARDIOVASCULAR:

Heart Sounds ________ Rate ____________ Rhythm ____________ Apical ________

Pulses: R/L Radial ___________ Brachial ________Femoral ______DP_____ PT ____

Capillary Refill ________________________ Skin color/temp _____________________ Edema/Location___________________________________________________________

Shunts/Location (bruit, thrill)_________________________________________________

Note: *Labs, Vitals & Medications for the cardiovascular system must be address

PULMONARY:

Respirations:

Rate/Min ______ Rhythm_______ Depth______ Effort/Ease_______ Pulse Ox __________

Breath Sounds (all lobes & bilateral comparison) R/L – Crackles (fine, coarse) Wheezes (inspiration, expiration), Diminished, Absent _________________________________________

Sputum/Secretions ______________________________________________________________

Oxygen Therapy/Rate:_______________________ Via_________________________________

RT Treatments (type, frequency)______________________ _____________________________

Chest Tubes _________________ Suction __________________ Drainage ________

Note : *Labs, Vitals & Medications for the pulmonary system must be address

GASTROINTESTINAL:

Diet__________________ Appetite ________________ Intake% ___________N/V ____

Kcal per day needed _________________________ receiving ___________________

Enteral nutrition: NG Tube _________________ G Tube ________________ J Tube _________

Mouth /oral mucosa______________________________Teeth/Dentures___________________

Abdomen: (soft, distended, ascites, stomas): _________________________________________

Bowel sounds: Location____________________ Activity________________________________

Bowel Patterns ______________ Last BM ___________ Stool Characteristics _______________

Note: *Labs & Medications for the gastrointestinal system must be address

GENITOURINARY:

Urine: Output (hourly, 8º, 12º, 24º) ___________ Characteristics __________________

Patterns of voiding _____________________________________ Catheter (type) ______

Genitalia: Female______________________________ Male_______________________

Sexual History (if applicable) _______________________________________________

Childbearing History (if applicable):__________________________________________

Note: *Labs & Medications for the genitourinary system must be address

6. Clinical Manifestation of Current Condition(s):

7. Patient Care Needs on your shift: (Discus your focus/concerns /care for the day)

8. Pathophysiology (Discuss pathophysiology of patient’s current and relevant past medical/surgical problems. Integrate with clinical data such as vital signs, labs, diagnostic test, procedures, medication use, and family history) Most patients have multiple diagnosis, ONE must be discussed:

Integrate textbook details with specifics of your patient. Make this very specific to the patient you have cared for. Cite references per APA (This generally requires 2 pages MINIMUM, double space)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Potential Complications (based on pathophysiology & referenced):

10. Nursing / Medical Therapies and Treatments:

(Utilize Potter and Perry& Lewis textbooks. Cite all rational & nursing implications)

This should be a comprehensive list of all the care provided to your patient during your shift. It may be care offered by other disciplines or by nursing. Examples include: ADL’s, ambulation, ROM, feeding, I&O, Vitals, Med pass, documentation. PT, ST, RT, OT, MD visit, repositioning, dressing changes, pt/family education, emotional or spiritual care, visit from chaplain, etc. etc. ALL care provided to a patient requires some level of nursing assessment and monitoring and has a nursing implication. This chart is designed for you to explain how busy you were providing outstanding care to your patient.

1. Individual/Family Developmental Stage and Family Dynamics:

C. Psychosocial Subsystem

(Discuss stages per Ericson and Maslow with rational based on your assessment of pt)

2. Cultural Influences/Health Beliefs and Values:

(Provide general information regarding pts identified culture first)

3. Individual/Family Challenges VS. Individual/ Family Strengths

4. Individual/Family Coping with the Current Stressors:

D. Spiritual Subsystem

1. Spiritual Assessment: {Ref. Taylor (2002); Potter & Perry (2013), Articles for a variety of spiritual assessment tools that can be used. Student must identify the specific model/tool/assessment used, the questions asked and the patient’s response including patient’s own words in quotations}

5. Link between spiritual assessment findings and overall health of patient:

Note: This is a great place to integrate the required research article, then link to specific patient issues

2

UNRS 367 / J. David

Community Referral, Follow-up Appointments, Medications, Treatments, Equipment, Support Groups, Home Health Needs and Long Term Care Concerns.

Provide a list of names and contact information in the patient’s neighborhood, for necessary support groups or other types of resources that might be required by patient upon discharge:

G. References and Reference list per APA guidelines

1. At least one general clinical or specialty article

a) Use articles from peer reviewed professional journals.

b) Must include copy of the article.

2. At least three Evidenced Based Research Article

a) Three research article required for full credit.

b) Include a copy of all the articles used to obtain credit.

c) Write a brief statement on how a research article was applied to nursing care for this specific patient.

3. Formatting & Appearance of completed work

a. APA format

b. Pagination

c. Title & Running header

d. Margins

e. Quotations

f. References

g. Spelling

h. Grammar