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Merced College
Vocational Nursing Program
Student Worksheet Patient Assessment
Student:
Date:
Instructor:
Unit Assigned/Room #:
Patient Initials:
PFN #:
DOB:
Team Leader:
Age:
Doctor:
Date of Admission:
Drug Allergies:
Language Spoken:
Food Allergies:
Code Status:
UNMET BHNs:
1.
Diagnosis/Surgery:
2.
Symptoms Causing Admission:
3.
Add’l Diagnosis:
4.
History of Patient:
LLPatient Drug Administration Record77
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!!What Should I Do Before Giving These Drugs!!
Vital Signs
Blood Pressure
Apical Pulse
Check Labs
Weight
Blood Sugar
Antidotes
Nutritional Considerations
PT able to Swallow Meds
Crush Meds
Do Anything Else??
T:\RN-LVN-Nursing\MyFiles\Nursing\LVN\1st Semester forms on-line\Student Worksheet Patient Assessment.rtf
LLMy Patient Will Need 77
Personal Hygiene:
Bath Type: Bed, Partial, Shower, Self
Linen Change: Partial, Complete
Perineal Care: Self, Assist
Shave
Skin Care
Heel Protectors
Ted Hose
Sitz Bath
Nutrition:
NPO, Tube, Regular, Special
Assist/Self Feed
Fluids:
Ice, Limit, Force, I&O, Other
Elimination:
BRP, BSC, Enema, Harris Flush, Foley, Other
Activity:
Safety:
Up & About Ad Lib, Up-in-Chair, Ambulate with Assist, Trapeze on Bed,
Turn q 2 Hrs, Cough and Deep Breath, Incentive Spirometer, ROM
Bedrails up, Restraints, Fall Risk
Wound:
Location:
IV Therapy:
Heplock, IV, Solution
Site
AV Shunt:
Location
Dressing
Thrill
Bruit
Palpable
Audible
Not Palpable
Not Audible
LLHOW OFTEN ASSESSED 77
Blood Pressure
TPR
Weight
Blood Sugar
(((ADD’L INFORMATION(((
T:\RN-LVN-Nursing\MyFiles\Nursing\LVN\1st Semester forms on-line\Student Worksheet Patient Assessment.rtf