Marymount University
Patient Worksheet
Student Name: _______________________ Date: _________ Location: _____________
PatientàIdentifying Data:
PatientàInitials or Room: _______ Age: _____ Sex: _____ Code Status: _________
Language: ____________ Admit Date: _______ Chief Complaint: _________________
Ethnicity: ____________ Religion: _____________
Admission Diagnosis: _____________________________________________________
Secondary Diagnosis (if present): ____________________________________________
Surgery and Date (if applicable): _____________________________________________
Assessment Data
Allergies:______________________________________________________________
Pertinent History: _________________________________________________________
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Present Illness: ___________________________________________________________
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Vital Signs: Time: ____T: _____ P:_____ R: ______ B/P: _______Pulse Ox:______
Time: ____T: _____ P:_____ R: ______ B/P: _______Pulse Ox:______
Activity Level: ___________________ Diet: ______________ Oxygen: ____________
IV: ____________________ Intake: ___________ Output: ___________ BM: ______
Drains:_________________________________________________________________
Blood Glucose: Time: ________ Value: ________ Time:__________Value:_________
Pathophysiology: (Related to patientàpresent condition and current findings)
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1
Lab Data:
Test
Result
Explanation of Abnormal
Results
Nursing Care Implications
Diagnostic Tests:
Test
Result
Purpose of Test
Nursing Care Implications
Systems Evaluation
Assessment Findings
A. Neuro
Pupils
Glasgow Coma Scale
Orientation
B. Cardiovascular
Skin Color/temp.
Capillary Refill
Radial Pulses and
Brachial pulses L/R
Pedal Pulses L/R
Edema 3ite
2
Rhythm
Mucus membrane
Skin turgor
C. Respiratory
Breath Sounds
Oxygen
Oxygen saturation
D. Gastrointestinal
Bowel Sounds
Abdomen
E. Nutrition
F. Genitourinary
Bladder/Catheter
G. Skin
Intact
Redness
Wounds
H. Musculoskeletal
Range of Motion
Gait/Posture
I. Pain and Comfort
Pain Score
Location
Intensity
J. Psycho/Social
Pt. adjustment to
hospitalization
Family/significant other
Support/interaction
K. Incision and/or
Dressing
Incision
Dressing
L. Knowledge
3
M. Discharge
Planning/Self Care
N. IV Site/Access
O. Fall Risk
Assessment
P. Activity/Functional
Assessment
Q. Hygiene
MEDICATION
DOSE/ROUTE
MEDICATIONS
INDICATION
SIDE FFECTS
NURSING CONSIDERATIONS
Nursing Diagnoses:
1. Nsg. Dx:_________________________________________________
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2. Nsg. Dx:__________________________________________________
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3. Nsg. Dx:__________________________________________________
4
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Time Plan (Scheduled activities, meds, treatments, nursing care, etc.)
0700
0800
0900
1000
1100
1200
1300
1400
Notes:
5
Care Plan:
1. Developed from one of the prioritized diagnoses. 2. Identify one short-term and one long-term outcome. 3. Identify
one intervention for each outcome. 4. Complete evaluation of outcomes.
Assessment
Nursing Diagnosis
Expected Outcomes
6
Interventions
Evaluation

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