Student: _________________________Date: ___________

School of Nursing: Pathophysiology

Nursing Process Data Form

Student: ___________________________________ Date of Care: __________________A. Identifying DataPatient 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. Biological1. 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 themedication based on their medical history & chronic conditions:

Generic/Trade Name
Dose
Frequency
Purpose

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:

Time
Temp F/C
Pulse (apical/radial)BPM
Resp/min
BP in mmHgR or L
Pulse Ox %

 
 
 
 
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PAIN ASSESSMENT:

Time
Pain Tool Used
Pain Rating
Pain Description (OLDCART)
Functional Pain Goal
PainMedication (or other care)

Response To
Intervention

LABORATORY DATA:

TEST

NORMAL
VALUE

RESULTS

RESULTS

RATIONALE FOR ABNORMALS

CHEMISTRY

Date / Time
Date / Time
State the reason why this pts. lab values are abnormal

Na

K

Cl

Mg

HCO3-

Glucose

BUN

Creatinine

T. Protein

Albumin

Uric Acid

Calcium

Phosphorus

Bilirubin

Alk Phos

ALT (SGPT)

AST (SGOT)

LDH

Cholesterol

LDL

HDL

Troponin

CPK isosMM, MB, BB

CBC
Normal
Date/Time
Date/Time
Rational for Abnormals:

Hgb

Hct

WBC

RBC

Diff

Plates

PT/INR

PTT

Other
Normal
Date/Time
Date/Time
Rational for Abnormals:

C & S

Cultures

ARTERIAL BLOOD GASES:

ABGs

RESULTS
Date / Time:

RESULTS
Date / Time:

pH

pO2

O2 Saturation

pCO2

HCO3

Overall Interpretación:

DIAGNOSTIC TEST & PROCEDURES:(Include 12 Lead EKG, CXR, Cardiac Cath, CT, MRI, Ultrasound, Endoscopy, Echocardiogram, etc)

Test:
Pt. Results:(Date/Time)
Normals:(referenced)
Rationale For Test Being Performed On This Patient:
Rationale for Abnormal Test Results:

INTAKE AND OUTPUT Past 24º Balance ___+/-____________
Does the patient have a positive or negative fluid balance as of this date? How much?______ML

Intake

1º
12º

Output

1º
12º

PO / Enteral

Source:

IV

Blood Products

Medications
IV Solutions/Parenteral Nutrition/Blood Products :

Name of Infusant:

Rate:

Site:
(describe the appearance)

IV Solution:

Lipids/TPN:

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.

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Efect:

Nursing Implications:

Pt/Fam teaching needs:

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Efect:

Nursing Implications:

Pt/Fam teaching needs:

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Efect:

Nursing Implications:

Pt/Fam teaching needs:

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Efect:

Nursing Implications:

Pt/Fam teaching needs:

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Effect:

Nursing Implications:

Pt/Fam teaching needs:

Medication:
Dose:
Route:
Frequency:

Classification:

Action:

Safe dose range for age/wt:

Rational for use in THIS patient:

Desired Effect:

Side Effects:

Toxic Efect:

Nursing Implications:

Pt/Fam teaching needs:

**Continue to copy the above chart as often as needed to include ALL Routine & PRNmeds**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 addressCARDIOVASCULAR: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 addressPULMONARY: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 address6. Clinical Manifestation of Current Condition(s):

Expected Manifestations. According to Literature for Each Medical Diagnosis and Surgical Procedure. Must be referenced and cited per APA
Assessment findings on Day of Care r/t each diagnosis. Include vitals, labs and physical assessment data(Date)___________

Dx #1:Dx #2:Dx #3:
Dx #1:Dx #2:Dx #3:

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):

Medical Diagnosis:
Potential Complication:

Dx #1

Dx #2

Dx #3

10. Nursing / Medical Therapies and Treatments:(Utilize Potter and Perry& Lewis textbooks. Cite all rational & nursing implications)

Treatment
Rationale for Treatment / Patient Application
Nursing Implications
Frequency

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

Individual/Family Challenges
Individual/Family Strengths

1.
1.

2.
2.

3.
3.

4. Individual/Family Coping with the Current Stressors:D. Spiritual Subsystem1. 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}

Spiritual Strengths
Spiritual Resources
Spiritual Needs

1.
1.
1.

2.
2.
2.

3.
3.
3.

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 issues2UNRS 367 / J. DavidCommunity Referral, Follow-up Appointments, Medications, Treatments, Equipment, Support Groups, Home Health Needs and Long Term Care Concerns.

Educational Needs
Evaluation of Teaching
Medications/Treatments/Equipment
Referrals / Follow-up / Disposition

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 guidelines1. At least one general clinical or specialty articlea) 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 worka. APA formatb. Paginationc. Title & Running headerd. Marginse. Quotationsf. Referencesg. Spellingh. Grammar

UNRS 367: Writing Case Study Tips
1. Pick a patient for your Case Study
2. Make sure that you know your patient’s diagnosis
3. Review the patient’s chart, MD, RN, and other multidisciplinary team’s notes, medications, lab values, etc.
4. Use the Data Form as your guide when you are gathering all the information about your patient.
5. Gather as much information as you can about your patient.
6. Interviewing the patient as well as family members caring for the patient.
7. Go to the library and search for 3 current (within the last 5 years) evidenced based research on the diagnosis/pathophysiology/plan of care of your patient.
8. Using the evidenced based research you have chosen, use this to understand and support the pathophysiology and treatment plan or plan of care for your patient.
9. In writing you paper, use the following subheading (see Data Form & APA Format)
a. Identifying Data
b. Biological System
c. Psychological Subsystem
d. Spiritual Subsystem
e. Nursing Diagnosis Collaborative Problem/Care Plan Evaluation
f. Discharge Needs
10. Have a complete Reference List – indicate all the resources you used including books. (APA format)
11. Proof read your paper
12. Check Appearance and APA format (must have title page and reference page)
Case Study Rubric
_____ 1. Identifying Data (5 pts.)
_____ 2. Biological System (5 pts.)
· Laboratory Data (5 pts.)
· Diagnostic Test & Procedures (5 pts.)
· Medications (5 pts.)
· Vital Signs (5 pts.)
_____ 3. Pathophysiology (10 points)
_____ 3. Psychological Subsystem (5 pts.)
_____ 4. Spiritual Subsystem (5 pts.)
_____ 5. Nursing Diagnosis Collaborative Problem/
Care Plan Evaluation (10 pts.)
_____ 6. Discharge Needs (5 pts.)
_____ 7. 3 Evidenced Based Research (6 pts.)
_____ 8. Reference List (5 pts.)
_____ 9. APA Format (5 pts.)
_____ 10. Organization and Appearance (5 pts.)
_____ 11. Data Form (10 pts.)
_____ 12. Body max 8-10 pages, not including title and reference page (5 pts.)

 
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