Patient Progress Notes<\/p>\n
Name of Student _______________________
\nStudent Number _______________________
\nHospital _______________________________
\nteacher name ___________________________
\nClinical Area ___________________________
\nWeek # ________________________________
\nDate Submitted ________________________
\nMark ___________ \/10<\/p>\n
BIOGRAPHIC DATA\tMarks\tStudent Marks
\nPatient Name (initial)<\/p>\n
–
\nAge
\nGender
\n1<\/p>\n
Admission Date<\/p>\n
Admitting Diagnosis
\n1<\/p>\n
Chief Complain<\/p>\n
Total Marks\t2<\/p>\n
PRESENT ILLNES\tMarks\tStudent Marks
\nP\tProvoke:
\n1
\nPalliative:
\n1
\nQ\tQuality:
\n1
\nR\tRegion:
\n1
\nRadiation:<\/p>\n
S\tSeverity:
\n1
\nT\tOnset:
\n1
\nDuration:
\n1
\nFrequency:
\nU\tUnderstanding Patient Perception:
\n1
\nTotal Marks\t8<\/p>\n
Past history\tmark\tSt. mark
\nMedical & surgical\t\t1
\nmedication\t\t1
\nimmunization
\nLife style\t\t1
\nFamily history
\nTotal\t3<\/p>\n
Literature Review<\/p>\n
Disease pathophysiology
\n(1 mark)\t\tMark
\nClinical manifestations
\n(1 mark)
\nAssessment and diagnostic findings
\n(1 mark)
\nMedical management
\n(1 mark)
\nNursing management
\n(1 mark)
\nTotal marks 5<\/p>\n
PHYSICAL ASSESSMENT
\nSYSTEM\tPATIENT FINDING\tMarks\tStudent Marks
\nNEURO\tLOC\t\u25a1Oriented \u25a1Alert \u25a1Lethargic \u25a1Sedated \u25a1Unresponsive
\n\u25a1Respond only to pain \u25a1Agitated \u25a1Calm \u25a1 Cry \u25a1Confused \t1
\nGCS\tMotor\u2026..\u2026. +Verbal\u2026..\u2026 +Eye\u2026\u2026… =
\nOther
\nSKIN\tHair\t\u25a1Thick \u25a1Thin \u25a1Dull \u25a1Shiny Color\u2026\u2026\u2026..\t1
\nNail\t\u25a1Flat \u25a1Curve \u25a1Convex \u25a1Clean \u25a1 Dirty \u25a1brittle Color\u2026\u2026\u2026\u2026
\nSkin Integrity\t\u25a1Intact \u25a1Dry \u25a1 Moist \u25a1Wound \u25a1Ulcer
\nSkin Color\t\u25a1Pink\/WML \u25a1 Pale \u25a1Jaundiced \u25a1Cyanotic
\nSkin Temperature\t\u25a1Warm \u25a1 Hot \u25a1 Cold
\nWound\/Ulcer\t\u25a1None \u25a1Yes
\nLocation\u2026\u2026\u2026\u2026 Size\u2026\u2026\u2026.. Border\u2026\u2026\u2026\u2026.Depth \u2026\u2026\u2026\u2026 Stage\u2026\u2026..\u2026
\nOther
\nCARDIAC\tEdema\t\u25a1None \u25a1 Yes +1 \/ +2 \/ +3 \/ +4 Location \u2026\u2026\u2026.\t1
\nCapillary Refill\t\u25a1Normal (1-2 seconds) \u25a1 Delayed (>3 seconds)
\nHeart Sounds\t\u25a1Normal S1\/S2 \u25a1Abnormal
\nArterial Pulses\t\u25a1Strong \u25a1Weak \u25a1Increased \u25a1Pounding \u25a1Absent
\nRhythm \t\u25a1Regular \u25a1 Irregular
\nOther
\nRESPIRATORY\tBreath Sound\t\u25a1Clear \u25a1Crackles \u25a1Wheezes \t1
\nCough\t\u25a1Absent \u25a1 Productive \u25a1 Non productive
\nSputum\/Secretion\tColor\u2026\u2026\u2026.. Consistency: \u25a1Thin \u25a1Thick
\nO2 Therapy\t\u25a1None \u25a1 O2 @ …… L\/M FIO2 \u2026\u2026 % Per:
\nOther
\nGastrointestinal\tDiet\t\u25a1NPO \u25a1 Reg \u25a1Clear \u25a1Soft \t1
\nAppetite \t\u25a1Good \u25a1Fair \u25a1Poor \u25a1Nausea \u25a1Vomiting
\nAbdomen\t\u25a1Soft \u25a1Firm \u25a1Distended
\nBowel Sounds\t\u25a1Active \u25a1Hyperactive \u25a1Hypoactive \u25a1Absent
\nStool \t\u25a1None \u25a1Formed \u25a1Soft \u25a1 Liquid Color\u2026\u2026\u2026 LBM \u2026..\/.\u2026..\/\u2026\u2026..
\nOther
\nGENITOURINARY\tUrine\t\u25a1Continent \u25a1Incontinent \u25a1 Foley Color\u2026\u2026\u2026..\t1
\nOther
\nMUSCLOSKELETAL\tROM\t\u25a1Full Limited \t1
\nAbnormality\t\u25a1Absent \u25a1Present Location\u2026\u2026\u2026.
\nOther
\nACTIVITY\tActivity\t\u25a1Dependent \u25a1Independent \u25a1Bedrest \t1
\nHygiene\t\u25a1Clean \u25a1 Dirty
\nOther
\nSAFETY\tPatient Safety Needs\t\u25a1Call bell in reach \u25a1Bed in Low position
\n\u25a1Breaks on \u25a1Side Rails up \u25a1ID band on \t1
\nOther
\nISOLATION\tIsolation precaution\t\u25a1Standard \u25a1Contact \u25a1Airborne \u25a1Droplet \t1
\nOther
\nLines\tInvasive Lines\tType\t1\tSite\tCondition\t1<\/p>\n
Total Marks\t11<\/p>\n
Lab investigation and diagnostic test
\nName of test \tNormal range (1)\tResult (1)\tSignificant (1)<\/p>\n
Total marks (3)<\/p>\n
Medication (1)
\nDrug name
\n Classification\tUses
\n(0.5 mark)\tSide effects
\n(0.5 mark)\tNursing considerations
\n(1 mark)\tPatient\/family education
\n(0.5 mark)
\nAssess:
\nAdminister:
\nPerform\/provide:
\nEvaluate:
\nTotal marks (2.5)<\/p>\n
Medication (2)
\nDrug name Classification
\nUses
\n(0.5mark) \tSide effects
\n(0.5 mark)\tNursing considerations
\n(1 mark)\tPatient\/family education
\n(0.5 mark)
\nAssess:
\nAdminister:
\nPerform\/provide:
\nEvaluate:
\nTotal marks (2.5)<\/p>\n
PRIORITY NURSING PROBLEMS (1)<\/p>\n
1.\t_____________________________________
\n2.\t_____________________________________
\n3.\t_____________________________________
\n4.\t_____________________________________<\/p>\n
ACTUAL NURSIING PROCESS\tMarks\tStudent Marks
\nAssessment : Subjective data:<\/p>\n
1
\nObjective data:<\/p>\n
1
\nNursing diagnosis<\/p>\n
1
\nPlan \/ Goal<\/p>\n
1
\nInterventions (not less than 4 actions)<\/p>\n
1.\t_______________________________________________________
\n_______________________________________________________
\n2.\t_______________________________________________________
\n_______________________________________________________
\n3.\t_______________________________________________________
\n_______________________________________________________
\n4.\t_______________________________________________________
\n_______________________________________________________
\n5.\t_______________________________________________________
\n_______________________________________________________
\n2
\nEvaluation
\n1
\nTotal Marks
\n7<\/p>\n
POTENTIAL NURSING PROCESS\tMarks\tStudent Marks
\nNursing diagnosis<\/p>\n
1
\nPlan \/ Goal<\/p>\n
1
\nInterventions (not less than 4 actions)<\/p>\n
1.\t_______________________________________________________
\n_______________________________________________________
\n2.\t_______________________________________________________
\n_______________________________________________________
\n3.\t_______________________________________________________
\n_______________________________________________________
\n4.\t_______________________________________________________
\n_______________________________________________________
\n5.\t_______________________________________________________
\n_______________________________________________________
\n2
\nEvaluation<\/p>\n
1
\nTotal Marks
\n5<\/p>\n
SMMARY FOR PROGRESS NOTES:<\/p>\n
Student Marks\tMarks\titems
\n2\tBiographic Data
\n8\tPresent Illness
\n3\tPast history
\n5\tLiterature review
\n11\tPhysical Assessment
\n3\tLad investigation and diagnostic test
\n5\tMedication
\n1\tPriority Of Nursing Process
\n7\tActual Nursing Process
\n5\tPotential Nursing Process
\n50%5 = 10\tTotal<\/p>\n
Clinical Performance List<\/p>\n
Procedure\tObserve\tPerform\tdate\tPreceptor Signature<\/p>\n
Name of Student _______________________ Student Number _______________________<\/p>\n","protected":false},"excerpt":{"rendered":"
Patient Progress Notes Name of Student _______________________ Student Number _______________________ Hospital _______________________________ teacher name ___________________________ Clinical Area ___________________________ Week # ________________________________ Date Submitted ________________________ Mark ___________ \/10 BIOGRAPHIC DATA Marks\u2026<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6901,6896,6899,6897,6900,6903,6902,6905,6904,6843,6898],"tags":[103,95,83,94,80,86,79,98,93,104,32,99,92,82,102,85,8,101,97,87,96,91,89,90,820,88,100,84,81],"class_list":["post-47704","post","type-post","status-publish","format-standard","hentry","category-affordable-dissertation-help-dissertation-help-tutors","category-assessment-brief-assignment-help","category-assessment-task-assignment-help","category-cheap-dissertation-writing-service-uk","category-custom-dissertation-writing-help","category-dissertation-help-services-uk","category-dissertation-proposal-help-uk","category-dissertation-writing-services-reddit","category-dissertation-writing-services-tiktok","category-dissertation-writing-services-uk-reviews","category-writing-dissertation-and-grant-proposals","tag-150-200-words-discussion-with-a-scholarly-reference","tag-200-300-words-response-to-classmate-discussion-question","tag-250-word-analysis-essay","tag-bachelor-of-nursing-assignments","tag-case-study","tag-essay-bishops-website","tag-expert-online-nursing-writing-service","tag-fast-nursing-papers","tag-freelance-case-study-writing-service","tag-health-medicine-assignment-help-australia","tag-health-care-and-life-sciences-paper-writers","tag-health-care-assignment-help-service","tag-healthcare-assignment-writing-services-by-top-writers","tag-healthcare-essay-writing-services-by-medical-academics","tag-healthcare-writing-help-by-certified-medical-academics","tag-i-need-to-submit-this-assignment","tag-medical-essay-writing-service","tag-nursing-assessment-help","tag-nursing-assignment-help","tag-nursing-assignment-help-australia","tag-nursing-assignment-help-sydney","tag-nursing-assignment-writers","tag-nursing-assignments-examples-assignment-help-nursing","tag-pay-someone-to-do-my-nursing-assignment","tag-professional","tag-professional-case-study-writers","tag-quality-nursing-essay-writing-service","tag-write-a-review","tag-writing-assignment"],"_links":{"self":[{"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/posts\/47704","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/comments?post=47704"}],"version-history":[{"count":0,"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/posts\/47704\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/media?parent=47704"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/categories?post=47704"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.essaybishops.com\/essays\/wp-json\/wp\/v2\/tags?post=47704"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}