Patient
Pathophysiology in two lines: what is going on in the body
Meds
| Time | Med · dose · route | Why this patient gets it | Check before giving |
|---|---|---|---|
Labs and tests
| Lab | Result | H · L | Why it matters here |
|---|---|---|---|
Vitals
| Time | |||
|---|---|---|---|
| BP | |||
| HR | |||
| RR | |||
| Temp | |||
| SpO₂ | |||
| Pain |
Assessment: what I found, head to toe
Priority problems
| # | Problem | Goal | What I will do | Did it work? |
|---|---|---|---|---|
| 1 | ||||
| 2 | ||||
| 3 |
Teaching · going home
Questions for my instructor
Who this sheet is for
Nursing students on a clinical day. It holds one patient: what you look up the night before, what you find on the shift, and what you need to ask your instructor.
Fill the patient block and the two lines of pathophysiology before you go in. For every med, write why this patient is getting it and what you check first, such as a heart rate or a lab. For every lab that is off, write why it matters for this patient, not just that it is high or low.
On the shift, add vitals and what you found head to toe. Pick up to three priority problems, a goal for each, what you will do, and before you leave, whether it worked. The teaching box is for what the patient needs to know before going home.
Blocks worth knowing
- Why this patient gets it
- the reason in this patient, not the drug class from the book
- Check before giving
- the vital sign or lab you look at before the med goes in
- Did it work?
- the evaluation: met, partly met, or not, and what you saw
Use initials only, never a full name, and follow your program's rules on what leaves the unit. It prints on one US Letter page and comes as a free PDF with no sign-up. Compare all the sheets or see the study guides for nursing school.