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I. ASSESSMENT Name: Click here to enter text. DOB: XX/XX/XXXX Date of Admission: Click here to enter a date. Assessment Date: Click here to enter a date. Admitting Diagnosis: Click here to enter text.

Past Medical History (include surgical history) Click here to enter text. Subjective history of current hospitalization (what led to current hospitalization?) Family and social history Click here to enter text. Summary of physical assessment (complete head-to-toe from hospitalization documentation) Click here to enter text. Allergies: Click here to enter text. Effects of diagnosis on daily living: Click here to enter text.

Current Medications (to add rows, click “insert row†on Table Layout tools) Name Dose Schedule Last taken Activity of Daily Living and Instrumental Activity of Daily Living Assessment (Place an “X†in the appropriate column) Activity Not applicable Dependent Semi Independent Bathing Dressing Personal Cares Continence Toileting Transferring Ambulation Climbing Stairs Eating Shopping Food Preparation Managing Medications Using the Phone Housework Laundry Transportation Managing Finances Total Patient Support System (based upon above assessment, who is available to provide care or support to patient) Name Relationship Availability Click here to enter text. Click here to enter text. Click here to enter text.

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Click here to enter text. Medical Follow-up Click here to enter text. Financial Summary Click here to enter text. II. DIAGNOSIS/PLAN List your top three priorities, create a nursing diagnosis, and create two goals for each Priority 1.

Click here to enter text. 2. Click here to enter text. 3. Click here to enter text.

Nursing diagnosis Click here to enter text. Click here to enter text. Click here to enter text. Client outcomes 1. Click here to enter text.

1. Click here to enter text. 1. Click here to enter text. 2.

Click here to enter text. 2, Click here to enter text. 2. Click here to enter text. III.

EDUCATION NEEDS Need Method Evaluation of learning Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. I. Future Medical Care - Routine Routine Care Description Frequency of visits Purpose Cost per visit Cost per year IV. FINANCIAL WORKSHEET Subtotal II. Future Medical Care - Specialty Description Frequency Purpose Cost per visit Cost per year Subtotal III.

Future Medical Care – Treatment Interventions Recommendation Frequency of procedure Purpose Cost per procedure Cost per year Subtotal IV. Medication Needs Name/dose Schedule Purpose Cost per month Cost per year Subtotal V. Supplies Supplies Schedule Purpose Cost per month Cost per year Subtotal VI. Diagnostic Testing Diagnostic Test Schedule Purpose Cost per month Cost per year Subtotal VII. Future Adjunctive Therapies Therapy Purpose Frequency Cost per month Cost per year Subtotal VIII.

Medical Equipment Equipment Purpose Purchase/Rental Cost per month Cost per year Subtotal IX. Transportation Mode Purpose Purchase/PRN Cost per month Cost per year Subtotal X. Home Furnishings and Adaptations Need Purpose Initial cost Upkeep Final cost Subtotal XI. Potential Complications Complication Estimated Cost Subtotal Financial Summary Description Cost per Year Non-recurring cost I. Future Medical Care - Routine II.

Future Medical Care - Specialty III. Treatment Interventions IV. Medication Needs V. Supplies VI. Diagnostic Testing VII.

Future Adjunctive Therapies VIII. Medical Equipment IX. Transportation X. Home Furnishings and Adaptations XI. Potential complications TOTAL: V. REFLECTION AND CONCLUSION

Paper for above instructions

I. Patient Assessment Overview

Assessment Details:

Name: [Patient Name]
DOB: [MM/DD/YYYY]
Date of Admission: [MM/DD/YYYY]
Assessment Date: [MM/DD/YYYY]
Admitting Diagnosis: [Diagnosis]

Past Medical History

The patient has a history of hypertension and type 2 diabetes mellitus. Previous surgical history includes an appendectomy performed in 2018. The patient reports managing their diabetes with oral medication and has been compliant with their hypertension treatment.

Subjective History of Current Hospitalization

The current hospitalization was prompted by exacerbation of diabetes, characterized by elevated blood sugar levels, fatigue, and polyuria. These symptoms led to severe dehydration, necessitating intravenous fluid therapy and adjustment of the diabetes management plan.

Family and Social History

The patient lives alone in an apartment and has a supportive family who checks in regularly. Family history includes hypertension, diabetes, and cardiovascular issues, suggesting a genetic predisposition to chronic illnesses.

Summary of Physical Assessment

A comprehensive head-to-toe assessment reveals the following findings:
- Vital Signs: BP 150/90 mmHg, Heart Rate 78 bpm, Respiratory Rate 18 breaths/min, Temperature 98.6°F.
- Skin: Warm, dry, no lesions.
- Cardiovascular: Regular rhythm, no murmurs.
- Respiratory: Clear lung sounds bilaterally.
- Abdomen: Soft, non-tender, normal bowel sounds.
- Extremities: No edema.

Allergies

No known drug allergies (NKDA).

Effects of Diagnosis on Daily Living

The patient's diabetes is influencing their daily living activities significantly. They require assistance with meal planning and grocery shopping, as maintaining a diabetic diet can be challenging. Fatigue is impacting their ability to engage in regular physical activity.

Current Medications

| Medication Name | Dose | Schedule | Last Taken |
|------------------|-----------|-----------|--------------|
| Metformin | 500 mg | Bid | [MM/DD/YYYY] |
| Lisinopril | 10 mg | Once Daily| [MM/DD/YYYY] |

Activity of Daily Living and Instrumental Activity Assessment

| Activity | Not applicable | Dependent | Semi Independent |
|---------------------|----------------|-----------|------------------|
| Bathing | | X | |
| Dressing | | X | |
| Personal Cares | | X | |
| Continence | | X | |
| Toileting | | X | |
| Transferring | | X | |
| Ambulation | | | X |
| Climbing Stairs | | | X |
| Eating | | | X |
| Shopping | | X | |
| Food Preparation | | X | |
| Managing Medications | | X | |
| Using the Phone | | | X |
| Housework | | X | |
| Laundry | | X | |
| Transportation | | | X |
| Managing Finances | | X | |

Total Patient Support System

- Name: [Family Member 1], Relationship: Son, Availability: Weekly visit
- Name: [Family Member 2], Relationship: Daughter, Availability: Twice a week
- Name: [Friend], Relationship: Close friend, Availability: Daily check-ins

Medical Follow-up

A follow-up appointment with an endocrinologist is necessary to reassess the diabetes management plan.

Financial Summary

The estimated cost for medication and treatment over a year, including physician visits and supplies, rounds up to approximately