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  • Student Physical Assessment Goals and Patient Information

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    Erin Travers
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    Patient Physical Assessment Student Goals for Today Patient initials Admission DX Medical history Primary M.D. Consult M.D. Physical Assessment Neuro Cardio Resp GI / GU Muscleskeletal Peripheral / Vascular Psychosocial Skin Other Latest Lab Results Age Gender adm date / / Diagnostic Labs ordered for today 1 2 3 4 5 Other Labs CBCs Date Na K Chemistry Date / Nursing Diagnosis: Teaching needs: Vital Signs Resp Time Temp Accuchecks

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    Physical Assessment worksheet

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    Patient Physical Assessment Student Goals for Today Patient initials Admission DX Medical history Primary M.D. Consult M.D. Physical Assessment Neuro Cardio Resp GI / GU Muscleskeletal Peripheral / Vascular Psychosocial Skin Other Latest Lab Results Age Gender adm date / / Diagnostic Labs ordered for today 1 2 3 4 5 Other Labs CBCs Date Na K Chemistry Date / Nursing Diagnosis: Teaching needs: Vital Signs Resp Time Temp Accuchecks

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    204 views1 page

    Student Physical Assessment Goals and Patient Information

    Uploaded by

    Erin Travers
    Patient Physical Assessment Student Goals for Today Patient initials Admission DX Medical history Primary M.D. Consult M.D. Physical Assessment Neuro Cardio Resp GI / GU Muscleskeletal Peripheral / Vascular Psychosocial Skin Other Latest Lab Results Age Gender adm date / / Diagnostic Labs ordered for today 1 2 3 4 5 Other Labs CBCs Date Na K Chemistry Date / Nursing Diagnosis: Teaching needs: Vital Signs Resp Time Temp Accuchecks

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    Patient Physical Assessment Student Goals for Today Patient initials Admission DX Medical history Primary M.D.

    Consult M.D. Physical Assessment Neuro Cardio Resp GI/GU Muscleskeletal Peripheral/ Vascular Psychosocial Skin Other Latest Lab Results Age Gender adm date / / Diagnostic Labs ordered for today 1 2 3 4 5 Other Labs

    Wbc

    Hgb Hcr / Cl CO2 / Bun Creat /

    Plat

    CBCs Date Na K

    BG

    Chemistry Date / Nursing Diagnosis: Teaching needs: Vital Signs Resp

    Time

    BP P/HR 800 / 1200 / 1600 / Intake and output Time IN Out 800 1200 1600

    Temp

    Time 700 1130 1700

    BG

    Accuchecks Coverage

    Diet

    Activity

    IV Therapy Foley feeding

    wounds bedbath

    saftey oob/ chair

    O2 therapy Tubes/Drains Ngt/Peg

    Time

    Pain locaion

    1\10

    Pain Assessment Pain Medication reassess 1\10

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