Student: _________________________

Date: ___________

School of Nursing: Pathophysiology

Nursing Process Data Form

Student: ___________________________________ Date of Care: __________________

A. Identifying Data

Patient 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. Biological

1. 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 the

medication 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 mmHg R or L	Pulse Ox %
				/
				/
				/
				/

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 isos MM, 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 & PRN

meds**

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 address

CARDIOVASCULAR:

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 address

PULMONARY:

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 address

6. 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 Subsystem

1. 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 issues

2

UNRS 367 / J. David

Community 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 guidelines

1. At least one general clinical or specialty article

a) 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 work

a. APA format

b. Pagination

c. Title & Running header

d. Margins

e. Quotations

f. References

g. Spelling

h. Grammar

 

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Nursing Questions and Answers

Question 1

When a provider receives a fixed amount to provide only the care that an individual needs from the provider, this is known as a _____________ payment.

capitation

fixed

premium

sub-capitation

4 points Save Answer

Question 2

The healthcare industry is heavily regulated by ____ and ____ legislation.

city; local

state; city

county; state

federal; state

4 points Save Answer
Question 3

When a patient signs a release of medical information at a physician’s office, that release is generally considered to be valid

for six months

for a single visit to the physician

for one year from the date entered on the form

until the patient changes insurance companies

4 points Save Answer
Question 4

When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to

accept assignment

assignment of benefits

authorize services

coordination of benefits

4 points Save Answer
Question 5

Which document is used to guarantee the patient’s financial and medical record?

encounter form

patient insurance form

patient ledger

patient registration form

4 points Save Answer
Question 6

The person responsible for paying the charges for services rendered by the provider is the

beneficiary

guarantor

guardian

subscriber

4 points Save Answer
Question 7

Which federal legislation was enacted in1995 to restrict the referral of patients to organizations in which providers have a financial interest?

Federal Anti-Kickback Law

Hill-Burton Act

HIPAA

Stark II laws

4 points Save Answer
Question 8

The recognized difference between fraud and abuse is the

cost

intent

payer

timing

4 points Save Answer
Question 9

The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the

coinsurance

copayment

deductible

premium

4 points Save Answer
Question 10

Which three components constitute the RBRVS payment system?

fee schedule, practice expense, and malpractice expense

physician work, practice expense, and geographical location

physician work, practice expense, and malpractice insurance espense

practice expense, malpractice insurance expense, and liability insurance expense

4 points Save Answer
Question 11

Mandates are

directives

laws

regulations

standards

4 points Save Answer
Question 12

Which type of HMO offers subscribers health care services by physicians who remain in their individual office setting?

closed panel

independent practice association

network model

staff model

4 points Save Answer
Question 13

HIPAA requires payers to implement rules called electronic __________, which result in a uniform language for electronic data interchange.

data interchanges

health records

medical records

transaction standards

4 points Save Answer
Question 14

The ambulatory payment classification prospective payment system is used to reimburse claims for what services?

inpatient

nursing facility

outpatient

rehabilitation

4 points Save Answer
Question 15

Breach of confidentiality can result from

discussing patient health care information with unauthorized sources

discussing the patient’s case in the business office

sending medical information to non-health care entities with the patient’s consent

sending patient health care information to the patient’s insurance company

4 points Save Answer
Question 16

When a patient elects to receive care from a non-PAR, the patient will accrue _____.

higher copays

higher out-of-pocket expenses

lower premiums

lower copays

4 points Save Answer
Question 17

When a number of people are grouped for insurance purposes, this is known as a(n)

adverse selection

insurance pool

member group

risk pool

4 points Save Answer
Question 18

Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engaged in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.

downcoding

jamming

unbundling

upcoding

4 points Save Answer
Question 19

The problem-oriented record (POR) is a systematic method of documentation that consists of

a database.

progress notes.

an initial plan.

all of the above.

4 points Save Answer
Question 20

Which of the following is an example of fraud?

billing noncovered services as covered services

falsifying certificates of medical necessity plans of treatment

reporting duplicative charges on an insurance claim

submitting claims for services not medically necessary

4 points Save Answer
Question 21

Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as

medical necessity

noncovered benefits

unapproved services

unauthorized services

4 points Save Answer
Question 22

A risk contract is defined as an arrangement among health care providers

stating that the HMO can provide services to Medicare beneficiaries only

that allows higher payments to the HMO if they treat Medicare beneficiaries

to make available capitated health care services to Medicare beneficiaries

to offer fee-for-service health care services to Medicare beneficiaries

4 points Save Answer
Question 23

Which of the following is an example of abuse?

billing noncovered services/procedures as covered services/procedures

falsifying health care certificates of medical necessity plans of treatment

misrepresenting ICD-10-CM and CPT/HCPCS codes to justify payment

submitting claims for services and procedures knowingly not provided

4 points Save Answer
Question 24

Preventive services

may result in the early detection of health problems.

are required by most insurance companies.

allow treatment options that are less dramatic and less expensive.

both a and c.

4 points Save Answer
Question 25

Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider’s failure to disclose that the injury was work-related.

adjudication

mediation

overpayment

unbundling

 

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Consider various guidelines for approaching controversial topics, gathering evidence, forming judgments, and constructing arguments to persuade others to agree with our judgments.
For this short assignment:
Think about the processes of forming a judgment and persuading others in your professional environment. Construct a 2- to 3-paragraph essay intended to persuade someone to agree with your position on a particular topic. Be sure to identify the topic and cite and explain the evidence you consider supportive of your position.
Refer to the 11 guidelines for constructing persuasive arguments, and apply two to three of them in your essay. Discuss the differences between civil and criminal courts. Is the line between these two courts absolutely definitive? If not, what types of cases might “blur the line” between both courts? Can you briefly describe a real world example where a case was tried in both courts?
Before 1972, scientists believed that the rings of Saturn were composed of gasses or dust; on tests, any student who claimed that Saturn’s rings were composed of solids was incorrect because the true answer was that the rings were a gas. Later scientific investigation has shown that the rings are, in fact, composed of solid matter. Did the truth change? Should these students retroactively be given credit? Which group of students originally knew the correct answer?
Similarly, in the 1950s and 1960s physicians knew that stress caused ulcers, although we now know that bacteria causes ulcers. What does this imply for our definition of the words truth and knowing?

 

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Nursing-Contemporary issue position essay

 

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