Nursing 326 AH I Clinical Preparation Sheet Student:_________________________Date:____________________________CLIENT X : Age: ____ Race_____ Gender:____ Ht.____ Wt.____ BMI [weight x 703/height in inches2] ____ Code Status VS [usual range]: T____-___P____-___R___-____BP______-_____/____-______ O2 Sat - Date of Admission:__________ Admitting Diagnosis/es:Surgical Procedures & Date:History of current illness [describe signs & symptoms; length of time]: Significant past health history (medical and surgical):Allergies_____________________________ and reaction:MD Ordered Interventions/Patient Plan of Care:VS frequency: q4 q8 q12 other O2 Sat Freq: O2 mode: cannula mask other Rate: L/minSCDs TED Hose I & O: Y N FS/BS frequency: AC & HS q6 Activity: Ad Lib Bedrest BRP Other Fall Precautions: Y N 1MD Ordered Interventions/Patient Plan of Care:Nutrition/Diet: NPO Regular NAS AHA CC Other Feeding Tube: Y N Tube Feeding (Type/Rate of Admin): Urinary catheter: Y N NG Tube: Y N Chest Tube: Y N Isolation Precautions: Y N Type: Organism: IV site (type): Peripheral PICC Central IVF type: Rate: ml/hr Treatment/Interventions: Dressings:Scheduled Tests/Procedures and Date:Significant lab tests such as CBC, H&H, electrolytes, urinalysis (date and results):Medications (dose/route/freq/time due):Usual health patterns (generally healthy vs. chronically ill):Desired outcomes in patient’s words:Support systems/patterns of coping (family/visitors):2Safety concerns: (Risk for Falls/Bleeding/Skin breakdown) Anticipated learning needs:Cultural considerations/impact on care:Nursing Diagnoses Identified:
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