FUNDAMENTAL CLINICAL PACKET
STUDENT NAME:
DATE:
CLIENT’S INITIALS:
HT:
COURSE: NUR 1022C
DATE OF ADMISSION:
WT:
AGE:
GENDER:
ALLERGIES:
BMI:
CODE STATUS:
RACE/ETHNICITY
CULTURALCONSIDERATIONS: (values, beliefs, customs, communication styles, behaviors, practices etc.)
RELIGION/SPIRITUAL CONSIDERATIONS:
OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES:
LIVING SITUATION/WITH WHOM: (home, assisted living, etc.)
SOCIAL HISTORY: tobacco (how much per day/per year), ETOH (how much per day/per year), illicit drugs,
family dynamics)
ADMITTING MEDICAL DIAGNOSIS:
CHIEF COMPLAINT/ CC: (What led up this admission and why is the client in rehab, skilled nursing facility or hospital?)
POTENTIAL OF MEDICAL COMPLICATIONS (COLLABORATIVE PROBLEMS) RELATED TO THE DIAGNOSIS:
1.
2.
SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses such as DM, COPD, etc.)
PAST MEDICAL/SURGICAL HISTORY: (including tobacco, ETOH, illicit drugs)
SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed and explanation)
CONSULTS: (IF APPLICABLE: include date, discipline and reason for consult)
PT:
OT:
RT:
SPEECH:
DIETARY:
CARDIAC:
OTHER:
OTHER:
DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test, and results)
CXR:
CT:
MRI:
ECG
OTHER:
OTHER:
OTHER:
DVT PREVENTION: Anticoagulation Medications/TEDS/SCD’s/ROM/Ambulation
Diagnostic
Test Name
Na+
Sodium
K+
Potassium
CLChloride
Glucose
BUN
Creatinine
WBC
Normal
Range
Purpose of
Test
Patient
Preparation
Patient Findings /
Results
Reason why your patient’s exam is
Abnormal
Diagnostic
Test Name
HGB
HCT
Platelets
Normal
Range
Purpose of
Test
Patient
Preparation
Patient Findings /
Results
Reason why your patient’s exam is
Abnormal
Medication
(Brand/Generic
name)
Indications
(Circle the reason
why your client is
taking the med.)
Prescribed dose,
Route, and
Frequency
Side Effects
Contraindications
What nursing assessment is needed prior to med
administration / lab-value associated with med / specific
things that you need to monitor/major side effect that
nurse needs to teach client
Medication
(Brand/Generic
name)
Indications
(Circle the reason
why your client is
taking the med.)
Prescribed dose,
Route, and
Frequency
Side Effects
Contraindications
What nursing assessment is needed prior to med
administration / lab-value associated with med / specific
things that you need to monitor/major side effect that
nurse needs to teach client
Report Quick Sheet (Please fill in all sections)
Patient’s Initials: ___________
Neurological
A & O/Confused: ______________
Room #: ___________
PAIN Management
Pain Scales (0-10)
Medication: ______________________
LOC: _______________________
HEENT
Pupils: ________________________
Hearing: _______________________
Frequency: ______________________
Speech: _____________________
Vision: ________________________
Last Dose: ______________________
Commands: __________________
Daily Tasks
□ Daily Weight (Y / N)
IV’S
#1: Location: _____________________
Accu-Checks (Y / N )
AC/HS or ______________________
□ Turn Q 2 Hr
Type/Gauge: _____________________
Time
Blood Sugar Units
________ ________ ____________
□ Patient Rounds Q1hr
Start Date: ______________________
□ I & O Total UOP___________
#2: Location: _____________________
□ Bed/Bath/Room Tidy
Type/Gauge: _____________________
□ Fresh Ice and Water
Start Date: ______________________
________ ________ ____________
________ ________ ____________
________ ________ ____________
Respiratory
O2: ___________ O2 Sat: _________
Chest Tubes: ___________________
Cough (Y / N )
Sputum; _________
RUL: _________ LUL: ___________
IVF/Drips
Vital Signs
Temp – HR – BP – RR – O2
Fluid: ____________ Rate: _________
Fluid: ____________ Rate: _________
Temp – HR – BP – RR – O2
Fluid: ____________ Rate: _________
RLL: _________ LLL: ____________
Respiratory Treatments (Y / N )
ABG: __________________________
Cardiac/Circulatory
Tele # _________ Rhythm ________
Musculoskeletal
Activity: _________________________
Gastrointestinal
Diet:___________________________
Heart Sounds ___________________
Assistive Devices: _________________
Tubes:_________________________
Chest Pain (Y / N )
PT Eval (Y / N )
Feedings: Rate:__________________
Pacemaker (Y / N )
RUE: ___________ LUE:___________
Bowel Sounds:__________________
Edema ________________________
RLE: ___________ LLE:___________
LBM:__________________________
Integumentary
Wounds:_________________________
Notes
Skin Temp _____________________
Genitourinary
Urine Description :_________________
Voids: Foley Bedpan
BSC
Dressing:_________________________
Dialysis:________________________
HEAD TO TOE ASSESSMENT
Each section needs to be filled out completely.
VITAL SIGNS
BP
Da y 1
Pulse Radial
Pedal
Apical
Rhythm
B=bounding; S=strong; W=weak; A=absent;
D=doppler
Respiration: Rate and quality
Temperature
Oxygen Saturation if applicable
Pain Assessment (scale 0-10)
Note presence, onset,
location, intensity
Frequency, duration.
Radiation
Precipitating factors, facial
appearance
Guarding, inability to focus,
change in VS
EGO INTEGRITY: Erickson: _____________
Physical Appearance:
Behavior and Thought processes:
Appropriate to Situation:
Memory intact:
Affect appropriate:
Memory Intact
Tobacco:
Alcohol:
Recreational Drug / Substance use:
Da y 2
HEAD TO TOE ASSESSMENT (continued)
Describe Skin: Intact, temperature, moisture. Note and describe on chart ANY of the following: rashes, wounds,
pressure ulcers, ecchymotic areas, scars, tattoos, IV site (anything applicable and visible). Number or label each area.
Hygiene (participation in ADLs)
(Assistance required)
Color
Turgor
Peripheral edema sites
Degree of edematous areas
(Use Scale Below)
Nail beds (color and angle)
Capillary refill (seconds)
Edema Scale:
1+ =barely detectable, 2mm
2+ =indentation of 4 mm
3+ =indentation of 5 to 7 mm
4+ =indentation 8mm or greater
Pupil Size:
Neurosensory:
Mark “X”
where
applicable
ORIENTED:
PUPILS:
PERRLA
Pupil Size
Prosthetic
Devices
Alert
Person
Equal
Place
R:
Glasses
Circulation: Mark “X” where applicable”
Absent
Edema
Warm
Perfusion
Restless
Lethargic
Comatose
Time
Unequal
Confused
Reactive
Sedated
Sluggish
L:
Hearing
Aids
Dentures
Other
Present
Dry
Site
Diaphoretic
Pattern:
Breath Sounds:
Respiratory
Even
Uneven
Shallow
Dyspnea
Clear where or if adventitious describe type and location
Cough
SOB @rest or exertion
Sputum amount and color
Hemoptysis
Orthopnea
O2 Therapy (type/amount)
Secretions:
Treatment:
Peripheral and or central cyanosis
Color of mucous membranes
Use of accessory muscles
Pain on Inspiration or Expiration
Other treatments
Activity/ Sleep:
(list any assistive
devices)
Activity:
ROM
Activity Restriction
Contractures:
Joint Swelling
Stiffness
Ambulation:
Steady Gait
PT/OT Assessment
Rest/Sleep:
Quality & Quantity of Sleep
STRENGTH:
RIGHT
ARM
LEG
LEFT
STRENGTH Code:
4= normal strength, grip strong or good pressure resistance can move, lift and
and hold extremity
3= grip weak and/or poor pressure resistance lifts and holds, can move, lift
and hold extremity
2= weak grip or pressure resistance lifts and falls back, can move and lift
extremity but cannot hold position
1= little or no grip or pressure resistance moves on bed, cannot lift or hold
0= no movement
ELIMINATION: Note any of the following food intolerance or allergies, N or V, change of bowel
habits, rectal bleeding or black tarry stools, use of laxative and type.
Oral mucosa:
Bowel sounds:
Bowel
movement:
Ostomy ( type)
Color/moist
Other
Active/hypoactive/ hyperactive/absent
Last BM
Frequency (Hx)
Character/Color
Note any abnormalities on the chart: areas of tenderness or pain, location of ostomy or none.
RUQ
LUQ
RLQ
LLQ
URINARY
Urine Last Voided:
Retention
Frequency
Nocturia
Polyuria
Quantity sufficient:
Anuria
Hematuria
Dysuria
Incontinent
Catheter Type:
Color
Critical Thinking Weekly Self - Evaluation
1. Identify 2 psychomotor skills you consider to be a:
STRENGTH
a.
b.
WEAKNESS***
a.
b.
***Indicate how you will improve your weak skills
2. List 3 goals (psychomotor or cognitive behaviors) you would like to strive for
the next week
a.
b.
c.
This self-evaluation will help your instructor in evaluating your clinical
experiences
Date:
Nurses Progress Note
NUR1022C – Fundamentals of Nursing
Patient Initials:
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Nursing Diagnosis Statement:
Maslow’s/Developmental Theory:
Nursing Assessment Date
(includes at least 3 subjective
data and / or objective data
that leads to the nursing
diagnosis)
Subjective
1.
Outcome/Goal – 1
long term goal & 2
short term goals
(Follow SMARTspecific,
measurable,
achievable, realistic,
timely criteria,
dated and timed)
STG 1:
Nursing
Interventions: ((3)
interventions for
each the STG and
(2) interventions for
the LTG) include a
frequency on each
intervention.
Rationales:
(Provide reason
why intervention is
indicated with
citations and page
numbers)
Implementation:
(Documentation)
What you did /the
response from the
patient or family:
include date, Action,
Response from the
patient
Evaluation: State each goal
as met, not met, partially
met “AEB”. If not metrevise it, state goal
discontinued and list why
modifications needed, date
and time. Care Plan status:
continue, revise,
discontinue
STG 1
1.
1.
1.
1.
2.
2.
2.
3.
3.
3.
2.
3.
Objective
1.
2.
3.
LTG 1:
LTG 1
1.
1.
1.
2.
2.
2.
1.
PATHOPHYSIOLOGY CARD
CONDITION/DISEASE:
DEFINITION:
A brief definition in your own words and include: the pathological process(es); organ(s) involved; nature of the
organ’s change; and physiological functions involved.
ETIOLOGY:
Include when applicable:
-Causative factor(s)
-Incidence
-Genetic factors
-Predisposing and contributing factors
PROGNOSIS AND COURSE OF CONDITION/DISEASE:
This should be a generalized prognosis, which can be sued to compare with to your patient. Do not write the
specific prognosis of your assigned patient; you may take care of patients with the same condition but
different prognosis.
CLINICAL MANIFESTATIONS:
-Subjective signs: What does the patient or family tell you?
-Objective signs: This can include the physical exam and the laboratory findings
TREATMENT:
-Dietary:
-Medication:
-Surgical:
-Psychosocial Considerations:
-Other:
***Once again, this is a generalized card; what you write is under this section should be able to apply to
MOST patients with this condition or disease.
COMPLICATIONS:
What signs and/or symptoms do you need to be aware of to prevent any complications?
PREVENTIVE MEASURES:
What generalized nursing measures could you institute?