FORMATTING EXAMPLES
TREATMENTS

DATE	TREATMENTS 	DESCRIPTION	EXPLANATION	
11-07	Oxygen	3 L/min NC	To manage her COPD	
11-07	Foley catheter	Indwelling foley	To manage urinary incontinence	

MEDICATIONS

NAME	CLASSIFICATION	ROUTE,
DOSE & TIME	NORMAL
RANGE	INDICATION
FOR CLIENT	SIDE
EFFECTS	NURSING 
IMPLICATIONS
TEACHINGS	
Generic:
digoxin

Trade:
Digitek
Lanoxicaps
Lanoxin	Therap:
Antiarrhythmics
Intropics

Pharm:
digitalis
glycosides	PO  O.25 mg
qd  2 PM	PO Adult  
0.125mg-0.5mg	Slow & 
  strengthen 
  heart rate	Arrhythmias
 Bradycardia

Vision:
  yellow
  blurred
	Monitor apical
  for one full 
  minute. 
Withhold < 60	
*Therapuetically - What they are used to treat                     
*Pharmacologically - How they work

LABORATORY WORK

DATE	LAB TEST	ABNORMAL
VALUE	NORMAL RANGE	REASON FOR 
AB VALUE	
11/7	WBC	12.3	5.0 - 10.0 (SI Units)	Infection/inflammation	
11/7	RBC	3.76	Male:        4.7 - 6.1  (SI Units)
Female:    4.2 - 5.4  (SI Units)	Anemia/COPD/Renal
failure	
11/7	HGB	11.3	Female:   12.0 - 16.0 g/dl
Male:    14 - 18 g/dl   
	Anemia/Renal Failure	

DIAGNOSTIC TESTS

DATE	TEST ORDERED	REASON FOR TEST	RESULTS/CLIENT’S
CONDITION	
11/4	Chest - AP	Verify progression/
  management of the 
  pneumonia
	Continued bilateral
  pneumonia not significantly     changed from two days prior	
11/5
	Fecal Occult Blood
	Blood in stool on 11/07
	The client still has blood
  in her stool.  Positive 4+	
11/5
	Clostridium difficile stool
	Investigate gastroenteritis
	Neg.  for Clostridium dif.     which is a bacterial infection    of the intestine.