COURSE SYLLABUS
VNSG 1260.501 (2:0:6)
CLINICAL PRACTICAL NURSING (LPN TRAINING)
LEVEL I
Vocational Nursing Program – Plainview Extension
Health Occupations Division
Technical Education Division
Plainview Campus
SOUTH PLAINS COLLEGE
Fall Semester - 2011
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PLAINVIEW
COURSE SYLLABUS
COURSE TITLE:
VNSG 1260.501 (2:0:6)
CLINICAL-PRACTICAL NURSING (L.P.N. TRAINING)
INSTRUCTOR:
Nursing Faculty / Clinical Instructors
OFFICE LOCATION
PHONE / E-MAIL:
Plainview Center – 104F
806-296-9611 – extension 4405 / sgriffin@southplainscollege.edu
OFFICE HOURS:
By appointment
SOUTH PLAINS COLLEGE IMPROVES EACH STUDENT’S LIFE
COURSE DESCRIPTION:
A health related work based learning experience that enables the student to apply specialized
occupational theory, skills, and concepts. Direct supervision is provided by the clinical
professional / instructor. Specific detailed learning objectives are developed for each course by
the faculty. On-site clinical instruction, supervision, evaluation, and placement are the
responsibility of the college faculty. Clinical experiences are unpaid external learning experiences.
Course may be repeated if topics and learning outcomes vary.
COURSE LEARNING OUTCOMES:
As outlined in the learning plan, the student will apply the theory, concepts, and skills involving
specialized materials, equipment, procedures, regulations, laws, and interactions within and
among political, economic, environmental, social, and legal systems associated with the particular
occupation and the business / industry; and demonstrate legal and ethical behavior, safety
practices, interpersonal and teamwork skills, communicating in the applicable language of the
occupation and the business or industry.
COURSE COMPETENCIES:
Student must complete with a grade of “P” (Pass) based on the course objectives and nursing
grading scale (75 or above) in order to move to Level II of clinical competencies.
ACADEMIC INTEGRITY:
Refer to (Plainview) Vocational Nursing Student Handbook (page 23) and the SPC College
Catalog (page 23). In addition, all students are expected to maintain professional conduct and
standards, and comply with all clinical guidelines as outlined in the Student Handbook.
SCANS & FOUNDATION SKILLS:
See Clinical Objectives
VERIFICATION OF WORKPLACE COMPETENCIES:
NCLEX-PN Licensure Exam eligibility following successful completion of the one-year
vocational nursing program.
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ATTENDANCE POLICY: (Student Handbook)
Level I Clinical – 1 absence
Student will be dismissed from the course if second
absence occurs.
**The student is responsible for notifying the Assigned Nursing Unit / Clinical Instructor if unable to
be at the assigned clinical site. The unit should be called at least 30 minutes prior to the time
scheduled for duty. When student does not call in before 6:45 AM, their patients will be
reassigned and they will be counted absent.
Tardies in the clinical area will not be tolerated. A student is considered tardy if he/she does not
report for duty at the scheduled time for that clinical area. A student who accumulates (2) tardies in
the clinical component will be counseled by the Program Coordinator. Three (3) tardies in the
clinical aspect of the program will be grounds for disciplinary action. **If a student is absent any
portion of a clinical shift, this will be considered as one absence. If a student must leave the clinical
site for any reason, he/she should report to the instructor assigned to the affiliate, and to the person
in charge so that patient responsibility or duties may be reassigned.
COURSE REQUIREMENTS:
Student must successfully meet all clinical competencies for Level I by the completion of this course.
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SOUTH PLAINS COLLEGE – PLAINVIEW
LEVEL I – CLINICAL OBJECTIVES
VNSG 1260.501
LEVEL I – CLINICAL PRACTICUM: The student should demonstrate satisfactory progress in the
following levels of performance toward competency of skills sufficient for entry into Level II of
clinical application. (C-1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 / F-1, 2, 3, 5, 6, 7, 8,
9, 10, 11, 12, 13, 14, 15, 16, 17)
1.
Provide nursing care within limits of vocational nursing knowledge, education, experience, and
ethical/legal standards of care.
2.
Assess for, initiate appropriate interventions, and report any unsafe environmental situation or
equipment.
3.
Employ correct handwashing techniques to minimize the risk of contracting or transmitting any
nosocomial organisms. Be knowledgeable of and practice standard precautions in the
implementation of nursing care.
4.
Utilize correct positioning and good body alignment to provide for the client’s health needs;
utilize various support aids for immobilization of body parts and protection of approximated skin
areas or bony prominences.
5.
Assess for and assist the client in rehabilitative efforts, including active or passive exercises
according to physician’s orders.
6.
Prepare the unoccupied, occupied, and surgical bed in the appropriate manner to provide a neat,
clean, and comfortable physical environment for the client.
7.
Provide for the therapeutic and personal hygienic needs of the client in the hospital or long-term
care setting.
8.
Accurately perform measurement of vital signs utilizing standard equipment; document findings
correctly in designated section of the medical record.
9.
Assist client in the use of appropriate equipment for elimination, measure and record accurate
output, and collect specimens of urine, feces or sputum.
10. Demonstrate the ability to assess nutritional needs in the total care of the client; accurately
measure and record food/fluid intake.
11. Admit, transfer, or discharge a client using correct protocol, incorporating a concern for the
physical and emotional well-being of the client.
12. Initiate appropriate interventions to meet the special needs of the client who requires assistance to
meet activities of daily living, is incontinent, is in traction or cast, or who has an ostomy.
13. Provide appropriate pre/post operative nursing care including: assemble required equipment,
complete necessary forms and records, provide relevant patient teaching, and implement care to
the patient returning to the nursing unit following surgery.
14. Provide daily care utilizing proper safety precautions and interventions in management of the
client receiving intravenous therapy.
15. Correctly apply equipment and implement nursing care to the client receiving oxygen therapy.
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16. Demonstrate the ability to insert or assist with the insertion of various types of enteral feeding
tubes and initiate appropriate safety precautions in caring for the client.
17. Demonstrate the ability to insert or assist with the insertion of nasogastric tubes utilized for
decompression of the intestinal tract; demonstrate knowledge of suction equipment utilized for
decompression and for clearing secretions from the pharyngeal tract.
18. Apply heat or cold treatment to a body part accurately, effectively, and safely.
19. Demonstrate the ability to implement isolation technique, including appropriate disposal of
contaminated articles and biohazard wastes according to OSHA guidelines; demonstrate
knowledge of specific isolation techniques employed in preventing the transfer of organisms by
various modes of transmission.
20. Assemble necessary equipment and assist the physician or physician assistant with a physical
examination.
21. Perform a focused systems assessment including normal and abnormal objective/subjective data to
assist in identifying health status and monitor change; identify common actual and potential health
care needs of the client; make observations that assist in formulating nursing diagnoses; evaluate
the results and effectiveness of care.
22. Begin to associate signs and symptoms with pathophysiology of client disorder/s; utilize
appropriate terminology in recording an assessment in the client’s medical record.
23. Identify, communicate with healthcare team, and report client care problems encountered in
practice to meet client needs.
24. Utilize resources within the work setting to assist in planning and decision-making.
GERIATRICS PERFORMANCE OBJECTIVES: (Inclusive of all Level I competencies /
foundations).
1.
Perform a nursing assessment of the geriatric client using a physiologic systems approach.
2.
Perform basic nursing skill procedures, modifying them as necessary to meet the identifiable
needs of the individual patient.
3.
Develop a basic nursing care plan for implementation of direct patient care to assigned patients
using the nursing process approach.
4.
Utilize effective therapeutic communication skills, both verbal and non-verbal, to develop a
meaningful relationship with the client and his/her family toward achieving a nursing outcome.
5.
Identify and implement rehabilitative nursing measures implicated by nursing diagnosis which
will increase or maintain functional ability.
REVIEWED / REVISED:
AUG 1999
AUG 2000
AUG 2001
AUG 2002
MAY 2003
AUG 2004
AUG 2005
AUG 2006
AUG 2007
AUG 2008
AUG 2009
AUG 2010
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AUG 2011
CRITERIA FOR EVALUATING STUDENT PROGRESS IN MEETING THE OBJECTIVES
(Based on DELC Competencies – Level I)
1.
Provides nursing care within limits of vocational nursing knowledge, education, experience, and
ethical/legal standards of care.
a. Demonstrates respect for other members of the health care team.
b. Utilizes the proper chain of command in reporting pertinent information regarding
assigned patients.
c. Maintains a professional code of conduct at all times while in the clinical setting.
d. Willfully accepts the responsibility of duties related to patient care learning experiences.
e. Maintains confidentiality of all information accessible in the clinical setting.
f. Utilizes clinical time appropriately to best serve the needs of the patient.
g. Demonstrates the ability to choose the best approach to a given clinical situation under
the supervision and guidance of the clinical instructor or clinical nursing personnel.
2.
Assess for, implement changes, and report any unsafe environmental situation or equipment.
a. Follows facility guidelines in regard to siderails and high/low positioning of beds
assuring client safety in these areas at all times.
b. Recognizes potentially hazardous conditions such as water on the floor, excreta on the
floor, objects blocking the hallway or pathways in client environment, dimmed lighting,
and water temperatures.
c. Reports any faulty or non-functioning equipment in patient rooms.
d. Eliminates any objects from the patient unit which could contribute to an accidental fall
or injury.
e. Orients client to the call light system and maintains the light accessible to the patient at
all times.
f. Follows facility regulations and utilizes appropriate protocol for application of and
supervision of any physical restraint.
g. Observes and promotes safety regulations in regard to clients receiving oxygen therapy.
h. Evaluates the environment for potential hazards to patient safety in each clinical
situation.
i. Identifies the location of fire extinguishers and fire alarm mechanisms on each unit.
3.
Employ correct handwashing techniques to minimize the risk of contracting or transmitting any
nosocomial organisms. Be knowledgeable of and practice standard precautions in the
implementation of nursing care.
a. Washes hands appropriately using standard precautions and medical asepsis guidelines.
b. Demonstrates knowledge and applies these standards in appropriate situations to protect
the client and self against bacterial contamination.
4.
Utilize correct positioning in providing good body alignment to provide for the client’s health
needs and to promote comfort through the use of various aids for support or immobilization of
body parts, approximated skin areas or body prominences.
a. Demonstrates ability to position patient in appropriate position, keeping the body in good
alignment.
b. Recognizes pressure points over bony prominences and takes measures to reduce
pressure to these areas (i.e., heel protectors, foam wedge pillows, pressure-relieving
mattress) and initiates steps to secure a physician’s order for such aid as appropriate.
c. Provides support for the back, knees, feet, arms, and head when placing the patient in
various positions through the use of positioning aids.
d. Demonstrates ability to carry out physician’s orders in situations where the client is
immobilized or positioned to promote healing or prevent injury.
e. Recognizes need for and takes nursing measures to prevent contractures such as
handrolls, positioning aids for body extremities, or supportive devices as indicated.
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5.
Assess for and assist the client in rehabilitative efforts, including active or passive exercises
according to physician’s orders.
a. Clinical rotation through allied health departments with observation of application to the
individual client situation by physical therapy personnel.
b. Demonstrates actual ROM performance, recognizing the tolerance level of the individual
client.
c. Teaches and encourages the client to engage in active range of motion exercises.
6.
Prepare the unoccupied, occupied, and surgical bed in the appropriate manner to provide a neat,
clean, and comfortable physical environment for the client.
a. Assesses the need for clean linen and determines articles of linen needed to facilitate a
clean client unit.
b. Assesses prescribed level of activity to determine which procedure of bedmaking will be
required.
c. Correct alignment of client in an occupied bed to promote a safe and comfortable
position.
d. Properly follows learned procedure steps in all types of bedmaking skills.
e. Disposes of soiled linen according to facility protocol and infection control guidelines.
7.
Provide for the therapeutic and personal hygienic needs of the client in the hospital or long-term
care setting.
a. Assesses the need for bathing, oral care, and other hygienic interventions, and the client’s
physical and cognitive ability to assist with hygiene procedures.
b. Provides oral hygiene as needed to the alert or unconscious client; assists the client who
is unable to perform self-care toward optimum restorative functioning.
c. Utilizes a back rub to stimulate circulation to the skin and provide therapeutic touch for
the comfort of the client.
d. Follows correct procedure in giving a bed bath, assisting the ambulatory client with
bathing, and providing assistance with teaching for the client receiving a sitz bath.
e. Performs perineal care procedures in a reassuring manner to reduce or avoid
embarrassment to the client.
f. Correctly documents procedures in the client’s clinical record.
8.
Accurately perform measurement of vital signs utilizing standard equipment, and document data
correctly in designated section of the medical record.
a. Measures and documents vital signs accurately and recognizes deviations from normal
values.
b. Recognizes what is meant by the individual client baseline data.
c. Demonstrates ability to measure body temperature by the oral, axillary, rectal, electronic
tympanic, or thermoscan methods.
d. Accurately counts and assesses the rate and quality of the apical, radial, or other
peripheral pulses.
e. Determines and records the rate, depth, and quality of respiratory exchange.
f. Accurately measures and documents blood pressure using the appropriate size cuff,
sphygmomanometer, and stethoscope.
g. Demonstrates an awareness of the relationship between and compares current assessment
to the baseline measurement.
9.
Assist client in the use of appropriate equipment for elimination, measure and record accurate
output, and collect specimens of urine, feces or sputum.
a. Properly position the patient on the bedpan and removes it without spilling the content;
utilizes a fracture pan when appropriate.
b. Places or assists the male patient to use a urinal using correct procedural technique.
c. Accurately measures output and records it appropriately in the clinical record.
d. Obtains specimens of urine, feces, or sputum using correct procedure and precautions.
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e.
Observes principles related to gravity drainage when caring for the client with an
indwelling catheter.
10. Demonstrate knowledge related to the importance of nutrition in the total care of the client; to
accurately measure and record client food/fluid intake.
a. Identifies all food items that are measurable as fluid intake.
b. Correctly measures and records the client’s oral fluid intake according to institutional
protocol.
c. Describes a well-balanced diet based on established guidelines.
d. Identifies therapeutic diets used in treatment of certain diseases and the appropriate
rationale.
e. Identifies foods that are permitted and restricted on each therapeutic diet.
f. Recognizes the content of the specific therapeutic diet in the process of serving meal
trays to the clients on a clinical unit.
g. Assists or feeds adult client with a diet of solid and liquid food items.
h. Serves and collects meal trays and nourishments using correct institutional procedure.
11. Perform a systems assessment including normal and abnormal objective/subjective data, begin to
associate signs and symptoms with pathophysiology of disorder, and utilize appropriate
terminoloty in recording an assessment in the client’s medical record.
a. Contributes to the data base of the nursing process by:
 Observing overt or expressed physiological, emotional, cultural, and spiritual
needs of the client.
 Measuring physiological responses of the client.
 Utilizes available resources of information.
b. Documents changes in health status which interfere with the client’s ability to meet basic
needs.
c. Documents positive and /or negative responses to client care.
d. Assesses situations in which the client needs basic information or support to maintain
health status.
12. Admit, transfer, or discharge a client using correct protocol, while demonstrating a concern for the
physical and emotional well-being of the client.
a. Completes a routine admission procedure utilizing the appropriate steps, including
orientation of the client to the hospital unit.
b. Completes an accurate assessment of the client on admission and documents the
information according to facility procedure in the client’s medical record.
c. Assists with patient transfer to another unit (students must be accompanied by a licensed
person for patient transfer between units).
d. Participates in and completes the correct procedure for patient discharge and discharge
teaching.
13. Initiate appropriate interventions to meet the special needs of the client who requires assistance to
meet activities of daily living, is incontinent, is in traction or cast, or who has an ostomy.
a. Reduces and prevents formation of pressure areas by recognizing pressure points and
initiating nursing interventions to avoid skin breakdown.
b. Recognizes the need for and initiates use of protective skin aids.
c. Assesses signs of impaired circulation in a casted extremity and initiates appropriate
action.
d. Changes an ileostomy or colostomy appliance using medical aseptic technique, observes
the skin condition and applies any prescribed treatment.
e. Provides incontinent care when indicated with promptness, kindness and understanding,
using facility procedural protocol.
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14. Provide appropriate pre/post-operative nursing care including: assemble required equipment,
complete necessary forms and records, provide relevant patient teaching, and implement care to
the patient returning to the nursing unit following surgery.
a. Provides preoperative teaching and instructions for the client and client’s family based on
their level of understanding.
b. Posts, explains, and implements NPO orders prior to surgery.
c. Performs any preoperative skin preparations as ordered.
d. Assists the patient in personal hygiene and removes jewelry, metal, prosthesis, dentures.
or bridges, make-up as per facility protocol.
e. Assures that a signed surgical consent is present on the client’s medical record.
f. Completes a preoperative checklist and reports any omission to the charge nurse.
g. Ensures the client’s safety after pre-operative sedation is given by raising siderails,
placing the bed in low-position, and instructing the client to remain in bed.
h. Completes the pre-operative entry in the nurse’s notes of the medical record according to
hospital routine, including the disposition of valuables.
(Post-operatively)
i. Collects appropriate equipment needed in client’s unit for the diagnosis, condition, and
surgical procedures performed.
j. Maintains an open airway for the unconscious or incapacitated client.
k. Promotes adequate ventilation of the lungs by encouraging the client to turn, cough and
deep breathe, using pillow splints as appropriate to support the operative site.
l. Assesses for and connects all tubes to appropriate system equipment.
m. Assesses vital signs until stable as ordered in physician’s orders.
n. Assesses all surgical sites and maintains dressings in a dry and intact state, reinforcing as
necessary.
o. Keeps an accurate record of intake and output from all sources; monitors the IV infusion
site.
p. Assesses hourly urinary output and recognizes normal vs. deviation from normal
amounts.
q. Provides for the safety of the client by using facility protocol for siderails or safety
devices.
r. Provides for the client’s comfort and alleviates pain through positioning, supportive
measures, and prescribed medications for pain.
s. Implements nursing actions to prevent discomfort and complications post-operatively
t. Promotes goals of early ambulation and the client’s return to independence within the
limitations of the diagnosis.
15. Provide daily care utilizing proper safety precautions and interventions in management of the
client receiving intravenous therapy.
a. Demonstrates ability to dress and undress a client receiving IV therapy by appropriately
removing the tubing from the infusion monitor and reestablishing an uninterrupted flow
of solution.
b. Assists the client with meals and self-care as needed.
c. Bathes the IV site or covers appropriately for bathing without causing pain to the client or
dislodging the IV infusion apparatus.
d. Assists the client receiving IV therapy to ambulate
e. Assesses the functioning of the IV line and regulatory mechanisms and reports any
improper functioning to the total patient care nurse.
f. Assesses the IV site for any signs of infiltration, reporting and recording any
irregularities.
16. Correctly apply equipment and implement nursing care to the client receiving oxygen therapy.
a. Identifies and documents various methods of oxygen therapy administered to clients
and demonstrates ability to apply various delivery methods to achieve maximum benefit
for the client.
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b.
c.
Demonstrates ability to regulate oxygen liter flow according to physician’s orders;
recognizes usual liter flow ranges for delivery method.
Recognizes and observes safety precautions necessary when oxygen is in use.
17. Demonstrate the ability to insert or assist with the insertion of various types of enteral feeding
tubes and initiate appropriate safety precautions in caring for the client.
a. Assembles items needed to insert a nasogastric tube for feeding purposes.
b. Prepares feeding according to physician’s orders and administers feeding at room
temperature.
c. Administers an enteral feeding using correct procedure, verifies placement of tube and
residual stomach content prior to initiating the feeding, and follows feeding with 30 ml or
prescribed amount of water to clear the tube.
d. Observes site of tube insertion for any redness or evidence of skin breakdown.
e. Observes patient for any adverse effect during and following administration.
f. Utilizes standard precautions in the implementation of this procedure.
18. Demonstrate the ability to insert or assist with the insertion of nasogastric tube utilized for
decompression of the intestinal tract; demonstrate knowledge of suction equipment utilized for
decompression and for clearing secretions from the pharyngeal tract.
a. Collects items needed to insert a nasogastric tube connected to suction.
b. Demonstrates ability to properlymeasure, dispose of, and record suction output as to
volume, color, odor, and consistency of content.
c. Recognizes indications that suction equipment is not functioning properly.
d. Provides oral care to the patient with a nasogastric suctioning device.
e. Irrigates suction tubing as indicated and per physician’s orders using correct procedure
and technique.
19. Apply heat or cold treatment to a body part accurately, effectively, and safely.
a. Correctly applies local heat to a body part using a heating pad, aquathermia pad, or warm
moist compresses.
b. Correctly applies cold to a body part using an ice pack or hypothermia blanket
c. Identifies clients who have a high risk of acquiring burns secondary to heat application
and initiates preventive interventions.
d. Demonstrates knowledge of underlying reason for treatment of a specific condition with
heat or cold therapy.
20. Demonstrate the ability to implement isolation technique, including appropriate disposal of
contaminated articles and biohazard wastes according to OSHA guidelines; demonstrate
knowledge of specific isolation techniques employed in preventing the transfer or organisms by
various modes of transmission.
a. Describes the difference between medical and surgical asepsis.
b. Demonstrates an understanding of differences which exist between isolation precautions
as outlined by CDC and/or facility protocol.
c. Prepares a unit for isolation as outlined in facility protocol.
d. Uses proper technique in donning and removing isolation gown and gloves
e. Applies a mask and correctly disposes of mask to retain safe isolation technique.
f. Uses a double-bagging method as per facility protocol to dispose of contaminated
articles, linen, and body fluids.
g. Collects specimens and transfers them to designated locations using appropriate OSHA
procedural guidelines.
h. Describes methods used to disinfect or destroy microorganisms and employs them in the
clinical area
21. Assemble necessary equipment and assist the physician or physician assistant with a physical
examination.
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a.
b.
c.
d.
e.
f.
g.
h.
Assembles all supplies and equipment required by the physician for intended
examination.
Prepares the client by providing instructions at the client’s level of understanding.
Positions and drapes the client to facilitate the exam and to avoid any unnecessary
exposure or embarrassment to the client.
Assists the physician by providing appropriate supplies and instruments or equipment as
needed; positions or repositions the client as necessary to complete the exam
Reassures and assists the client as needed during the procedure.
Collects, cleans, disposes of, or replaces supplies and equipment as indicated during the
procedure.
Implements physician’s orders for any collected tissue specimens during the examination.
Records all pertinent information in the medical record.
22. Perform a basic assessment to assist in identifying health status and monitor change, identify
common actual and potential health care needs of the client, make observations that assist in
formulating nursing diagnoses, and evaluate the result and effectiveness of care.
a. Contributes to the development of individual nursing care plans by reporting objective
and subjective data which are relevant to the needs of the client.
b. Demonstrates beginning skills in the utilization of the nursing process to formulate a plan
of care for clients with less complex needs.
c. Determines expected outcomes and evaluates the effectiveness of nursing actions.
d. Demonstrates a scientific understanding and rationale for nursing interventions.
23. Identify, communicate with healthcare team, and report client care problems encountered in
practice to meet client needs.
a. Describes and reports areas for client care and teaching needs.
24. Utilize resources within the work setting to assist in planning and decision-making.
b. Uses all sources of information including patient, family, physician, medical record,
resource manuals, textbooks, and members of the healthcare team.
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NURSING CARE PLAN – VNSG 1260.501
FALL SEMESTER
Student_________________________________________
Date_________________
Instructor_______________________________________
Patient Information:
Admit Date___________________
M / F: ________________ Physician____________________ Allergies:
_________________________________________
Medical Diagnosis:
Primary Diagnosis: (what is written on admission sheet under “admission diagnosis”)
Secondary Diagnosis: (Any long standing health problems)
Surgical Procedure: (Applicable only if surgery done on this admission)
DATA COLLECTION
SUBJECTIVE DATA:
CHIEF COMPLAINT: (Signs and symptoms experienced by client prior to seeking medical attention,
and since admission)
PAST MEDICAL HISTORY: (Past illnesses – including past injuries, hospitalizations, surgeries and
other major health problems / medications taken upon admission)
FAMILY HISTORY: (Include any significant health problems among blood relatives, both physical or
mental)
PSYCHOSOCIAL / CULTURAL / SPIRITUAL:
Occupation – (if retired, previous work)
Support system – (family, friends, church)
Ethnic / cultural influence
Religious preference
Behavior / affect
Communications
Coping ability
OBJECTIVE DATA: (Physical Assessment)
Vital Signs:
Admission
Day 1
Day 2
T_____
T_____
T_____
P_____
P_____
P_____
R_____
R_____
R_____
/ Weight: ________lb
BP_____/_____
BP_____/_____
BP_____/_____
Pain_____
Pain_____
Pain_____
Admission:
Height: (ft ____in_____)
(________ (Kg)
IV Therapy:
Solution______________Site_________________Rate______________________
Site Assessment (IV or HL) __________________________________________________________
Diet: _______________________________________ Activity: __________________________________
Oxygen Therapy:
Liter flow_____________ Method_________________O2 Sat________________
PT: ______________________________________ OT: ______________________________________
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SYSTEM TO SYSTEM ASSESSMENT (Data collection you will use to document your initial assessment in the
patient’s clinical record. This is a systematic method to assist you in learning physical assessment.
NEUROLOGICAL:
DAY 1
DAY 2
LOC –
Orientation –
Speech –
Movement of extremities –
Hearing –
Eyes (PERRLA) –
Any numbness or paralysis –
Hand grip –_________________________________________________________________________________________________
RESPIRATORY:
Airway –
Skin color –
Rate, effort, depth –
Use of accessory muscles –
Any SOB with activity –
Breath sounds –
O2 sat –
Oxygen therapy - ___________________________________________________________________________________________
CARDIOVASCULAR:
Heart rate, rhythm, quality –
Peripheral pulse / bilateral –
Apical pulse –
Capillary refill –
Neck vein distention –
Chest pain or radiating pain –
Skin temp / color____________________________________________________________________________________________
GASTROINTESTINAL:
Abdomen contour (round, flat, distended, soft) –
Tenderness (location) –
Bowel sounds –
Bowel habits (last BM) – (Describe BM if occurs on your shift) –
Condition of mouth / dentition –
Food / fluid intake –
Diet tolerance (% of each meal) –
Any Nausea/Vomiting? –
_________________________________________________________________________________________________
URINARY:
Continent or Incontinent –
Color, consistency, amount of urine output –
Toileting (BRP or ad lib) –
Assistance required –
Bedpan or urinal –
Foley catheter – Size_______ / color / amount of output –
Bedside commode-__________________________________________________________________________________
MUSCULOSKELETAL:
Muscle strength / weakness –
Posture / gait (any stooping or shuffling) –
Joints (any swelling, stiffness, pain) –
Assistive devices (walker, cane, crutches, prosthesis) –_____________________________________________________________
REPRODUCTIVE:
Genitalia (Normal M/Fe) –
Any noted –
Swelling –
Lesions –
Masses –
Abnormal Discharge –
Absence of – ______________________________________________________________________________________
INTEGUMENTARY:
Skin turgor (use forehead or upper chest in elderly) –
Lesions –
Bruising / rashes / scars –Texture –
Nails / hair –
__________________________________________________________________________________________________________
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PLANNING
NURSING DIAGNOSIS # _________________
ACTUAL / POTENTIAL (circle one)
_____________________________related to ___________________________________
ASSESSMENT DATE BASE: (Signs / symptoms or data that support this nursing diagnosis as
appropriate for this patient and this problem)
EXPECTED OUTCOMES: (Measurable criteria to describe these outcomes you expect to see as a result
of the planned intervention.)
INTERVENTIONS
SCIENTIFIC PRINCIPLES/RATIONALS
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6..
7.
7.
8.
8.
9.
9.
EVALUATIONS OF EXPECTED OUTCOMES: (Be specific in your descriptions of the outcome !)
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PLANNING
NURSING DIAGNOSIS # _________________
ACTUAL / POTENTIAL (circle one)
_____________________________related to ___________________________________
ASSESSMENT DATE BASE: (Signs / symptoms or data that support this nursing diagnosis as
appropriate for this patient and this problem)
EXPECTED OUTCOMES: (Measurable criteria to describe these outcomes you expect to see as a result
of the planned intervention.)
INTERVENTIONS
SCIENTIFIC PRINCIPLES/RATIONALS
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
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EVALUATIONS OF EXPECTED OUTCOMES: (Be specific in your descriptions of the outcome!)
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PLANNING
NURSING DIAGNOSIS # _________________
ACTUAL / POTENTIAL (circle one)
_____________________________related to ___________________________________
ASSESSMENT DATE BASE: (Signs / symptoms or data that support this nursing diagnosis as
appropriate for this patient and this problem)
EXPECTED OUTCOMES: (Measurable criteria to describe these outcomes you expect to see as a result
of the planned intervention.)
INTERVENTIONS
SCIENTIFIC PRINCIPLES/RATIONALS
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EVALUATIONS OF EXPECTED OUTCOMES: (Be specific in your descriptions of the outcome !)
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Examples of Scientific Support for Nursing Interventions (Rationales)
Nsg Dx: Activity Intolerance
Intervention: Monitor V/S during and after activity. Note any increase in heart rate, BP,
resperations, dizziness, dyspnea, tachypnea.
Rationale: Cardiopulmonary changes may result from attempts by heart and lungs to
supply adequate amounts of oxygen to the tissue during activity. Changes may indicate
oxygen available is being used by primary organs is insufficient to meet cellular demand
for increased energy productivity.
Intervention: Assist patient to prioritize ADL’s and desired activities. Alternate rest
periods with activity periods.
Rationale: Preserves and maintains energy level while alleviating strain on the cardiac
and respiratory system. Rest periods provide time for oxygen to reach the cellular level to
meet body demands for energy production.
Intervention: Provide quiet, non-stimulating environment.
Rationale: Rest is needed to lower body’s oxygen requirements – reduces strain on heart
and lung.
Intervention: Elevate head of bed as tolerated.
Rationale: Enhances lung expansion to maximize oxygenation for cellular use.
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