Patient Initials:
Student:
Rm #:
Date(s) of Care:
PEDIATRIC CLINICAL PREP SHEET
Date of admission:
Age:
Chief complaint:
Sex:
Adm. Wt.
Allergies:
Admitting diagnosis:
Diet:
Date and type of surgery:
Activity Order:
IV type & site:
PMH / Chronic conditions:
IV solution & rate:
Treatments:
Oxygen:
Other disciplines involved in care of client (e.g.
respiratory, physical or occupational therapy, social
service, etc.)
Labs:
Other:
Significant abnormal lab values
Why are they abnormal?
How are they being corrected?
1. _______________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
Diagnostic Procedures
Results
Purpose (if unfamiliar to you)
Patient Prep & Post Care
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
Tubes, lines, drains or treatments
assessment/documentation
Purpose (if unfamiliar to you)
Nursing
1. _______________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
Quick assessment
Airway
Breathing
Circulation
Intake
Output
Pain
Safety
End-of-Shift list







Charting
MARs
Signatures
I&Os
Goodbye to pt.
Report to RN
Pockets
 No patient ID on papers
Cabrillo College ADN Program
C.Madsen/12/1/2005/rev Fall 09; Fall10
1
Patient Initials:
Student:
Rm #:
Date(s) of Care:
Growth & Development Assessment
Textbook
Observations of Your Patient
Physical
Motor
Social &
Language
(Eriksen)
Cognitive
(Piaget)
Other
Developmental
notes or
observations
(for use on
NSM circle).
Post-Clinical
What teaching (formal or informal) did you perform [or did you witness] for this patient &/or the family?
 If family not present – what things did you see that might be areas of teaching after assessing parent’s
knowledge?
Areas I was strong in:
Cabrillo College ADN Program
C.Madsen/12/1/2005/rev Fall 09; Fall10
Areas needing improvement:
2