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CRITICAL THINKING SUMMARY

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Medical or Surgical Diagnosis

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PATHOPHYSIOLOGY: of diagnosed disease (2 Sentences or less)

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MEDICAL HISTORY:

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; SURGICAL HISTORY:

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, SOCIAL HISTORY: (Lives alone? Smoker? ETOH? Works?)

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' CLIENT'S SYMPTOMS of the diagnosed disease include

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IS THE PRESENT ILLNESS\CONDITION r\t MEDICAL HISTORY?

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; COMPLICATIONS:
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If this client's condition were to worsen, what would be the most likely reason? OR
If your patient is a surgical patient, what are the worst possible complications?

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CRITICAL THINKING SUMMARY

COMPLICATIONS CONT.

How v:ould you know this is happening? (Changes in ViTAL SIGNS, MEiHAL STATUS, SK1N,LUNG\HEART assessment)

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What v;ill you do if this happens (as a nCJrse) PRN Med1sations? Increase Oxygen? Apply Pressure? Call MD? Call Family In?

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TODAY'S PROGRESS NOTES:

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If Consults Done. (surgery\cardiology\pulmonology etc.) what was v;ritt'?n.

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CRITICAL THINKING SUMMARY

r<.G: (Please print a strip and tape it here)

Rate
PR Interval
ORS Interval
- - - QT Interval - i'>iarne the iviOST important Thing That You Taught Your Patient

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If You're Patient Was At Risk For Re-Admission, Why:

How Could You Help Ensure That Your Patient Maximized Their Health:

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The best thing about this week was:

The worst thing about this week was:

Goals for this upcoming week are:

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CBC\Blood Gases and Cultures Review and Tracking

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If there <ire results outside of the normal r<inges - (Listed on the back of this form) - Please indic<ite what the patient's symptoms were <ind how they became <ibnormal.
If <i tre<itment or medie<Jtions wPre given, wh<Jt w<Js the piltient's response? (Ch;inges in l;ib v<ilues).

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If there ;ire results outside of the normzil r;:inges - (Listed on the b<ick of this form) - Ple<ise indicate what the patient's symptoms were ;ind how they bec;:ime abnormal.
If zi treatment or medications were given, wh;:it wzis the p;itient's response? (Ch;inges in lab values).

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PHYSICIAN PRESCRIBED MED/CATIONS HOME AND HOSPITAL

Home Medications

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(Just Look at Orders!)

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Ex1~an<1tion!)

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Risk for bleeding, Harmful to Damaged Kidneys

Watch for rebound HTN, Tachycardia

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