RN 225, Advanced Med/Surg Nursing:
Care of the Adult Clinical
CLINICAL FORMS
1
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
CRITICAL THINKING WORKSHEET
CLINICAL DATA COLLECTION SHEET
Students: __________________________________________________________________________
Date care given: _________________
Patient’s Initials: _____________________Age/Sex: ________Religion: ______________________
Primary Language: ________________________Occupation: _______________________________
Admitting Diagnosis: _______________________________ Date: _________Allergies: ________________
History of present illness:(precursors leading up to this hospitalization) ______________________________
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Health Hx: _____________________________________________________________________________
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Discharge Plan: __________________________________________________________________________
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Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Physical Assessment: Systems Review
Focused physical exam
Neurological: LOC, GCS,
etc.
Findings:
Nursing implications:
Respiratory:
Lung sounds, O2 Sats, etc.
Cardiovascular:
Gastrointestinal:
BS, last BM, etc.
Genitourinary:
Voiding? Foley? etc.
Immune: Isolation?
Musculo/skeletal: Mobile?
Strength scale? ROM?
Endocrine: pertinent to this
client, diabetic, thyroid?
Nutrition:
Diet, Wt:
Integumentary:
Wounds? Braden scale,
etc.
Psychosocial:
3
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Laboratory Values: List ALL normal lab values in column #2, the “Normal Values” column. There
should be no blank boxes in this column. In column #3 list ALL lab values/diagnostics that have been
done on YOUR patient, whether normal or abnormal. Column #4 demonstrates your critical thinking.
In this column state your interpretation of the lab value for YOUR patient. Why is this value being
measured? How is this value significant to YOUR patient? What else will you consider? What meds
affect this value? DO NOT COPY FROM A TEXTBOOK AS THIS INFO IS PERTINENT ONLY TO
THIS PATIENT.
CBC
Normal
values:
Patient
value:
Interpretation:
WBC
Hgb
Hct
RBC
Platelets
Differential
Bands
Lymphocytes
Monocytes
Neutrophils
Electrolytes/Comp Panel
Glucose
Na+
K+
ClCO2
Ca++
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Mg++
PO4BUN
Creatinine
Albumin
Protein
AST
ALT
SGPT
Alk Phos
Bili
Amylase
Lipase
Coagulation:
PTT
PT
INR
Cardiac:
CPK/isoenzymes
Troponin
Myoglobin
LDH
Urine:
UA (dip stick and/or
micro)
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Carrington College
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ABG’s:
PH
PCO2
HCO3
PO2
O2 Sat
Other Lab Values
Vanco/gentamycin trough
(peak?)
ESR
Blood cultures
Urine culture
Sputum cultures
Wound cultures
PSA
Other
Other
Other
Diagnostic Tests (XRAY,
CT, MRI, US, etc.)
Date:
Findings:
Nursing Implications:
6
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LVN to RN Advanced Placement Associate Degree RN Program
Admitting Diagnosis & Relevant Medical Diagnoses:
In your own words, list the diagnoses in order of importance including patient’s signs & symptoms
and the pathophysiology of the diagnosis. You need to be able to clearly identify and connect the
patient’s signs and symptoms with the pathophysiology.
Clinical Pathophysiology:
Nursing foci:
1.
1.
2.
2.
3.
3.
4.
4.
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Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Nursing Care Plan:
Nursing Diagnosis:
Plan: *
Nursing Interventions:
1.
1.
1
Evaluation: (of client’s
response) Goal met/unmet?
2.
3.
4.
2.
1.
1.
2.
3.
4.
3.
1.
1.
2.
3.
4.
*Plan: SMART – Specific, Measurable, Attainable, Realistic, Time Bound
8
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Recommendations: (Look at your patient holistically and examine what else needs to be done, advocate for
your patient. What did we miss as a healthcare team? i.e. consults, therapies, management, diagnostic
examinations, etc.)
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9
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
MEDICATION INFORMATION SHEET
Patient’s Initials:
Room #:
Diagnosis:
Medication
Allergies:
Action/Indications
Nursing Implications/Side Effects Pertinent
Lab Values/Vital Signs
In your own words list the above
information pertinent to this patient.
Rx:
Classification:
Route:
Dose:
Rx:
Classification:
Route:
Dose:
Rx:
Classification:
Route:
Dose:
Rx:
Classification:
Route:
Dose:
Rx:
Classification:
Route:
Dose:
Rx:
Classification:
Route:
Dose:
10
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LVN to RN Advanced Placement Associate Degree RN Program
CLIENT TEACHING PLAN
Student: _________________________________________________________________________
Date: _____________
Patient Diagnosis:
Course:
______________________
Age:
Procedures:
Potential Barriers to Learning:
 Language
___________________________________________________
_____________________________________________________________________
 Ability to Learn
______________________
________________________________________________________________
 Motivation
___________________
____________________________________________________________
 Culture
___________________
______________________________________________________
______
 Sensory/Perceptual
_________________________________________________________________________________
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 Support System
_______
_____________
______
______________________________________________________
 Other
_______
_____________
____________________________________________________________
Family/Caregiver present for patient teaching:  Yes  No
Variances:_______________________________________________________________________________
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_______________________________
Assessment of Learning Needs:
___________________________
_________________________________________________________________________________
_________________________________________________________________________________
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11
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Plan:
1.
__________________
____________
__________________
______________________________________________________________________________
2.
_____________
_________________________
________________________________________________________________________
3.
____________
_________________________
________________________________________________________________________
4.
__________________
_________________________
________________________________________________________________________
Interventions (nursing action):
1.
___________________
_________________________
________________________________________________________________________
2.
__________________
_________________________
________________________________________________________________________
3.
____________
_________________________
________________________________________________________________________
4.
____________
_________________________
________________________________________________________________________
Evaluation:
_________________________________________________________________________________
_________________________
________________________________________________________________________
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Carrington College
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Report: Beginning of shift:
Vital signs/Pain:
Assignment
Reporting Off-- Report:
Vital signs/Pain:
Resp/O2 sat/O2:
Resp/O2 sat/O2
IV:
IV:
CV:
CV:
GI:
GI:
GU:
GU:
MS:
MS:
Skin:
Skin:
Labs:
Labs:
Misc:
Misc:
Kardex Information:
Activity level: ______________________________ Diet: ________________________________
PT/OT: _______________ RT: __________________ Suction:_______Oxygen: _____________
Respirator: Trach: _______________________________________________________________
Vital Signs: ________ Frequency: __________ I& O: 24hr In _______ Out _____ 8hr in______ out
______
Fluids: IV: _____________________________________________ Saline Lock: ______________
GI: Bowel Care: ________________________________________ Enterostomy: ______________
Nutrition: Diet: ______________Tube Feeding: ___________________Residual ck: ____ Wt.:
_____
Glucose check: _______________________ when: result_________________________________
GU: Urinary Care: Foley? ___________________________________________________________
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Carrington College
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Immune: Wound: Skin Care:
Treatments:
Client Assessment Tool
(students will only be required to do a complete Client Assessment Tool once, subject to the instructor’s
evaluation and recommendation for improvement/revision)
Client Initials: __________ Age: ________ Diagnoses: ______________________________
Cognition/Perception/Communication/Interaction
Level of Consciousness:  Alert
 Lethargic  Semicomatose
 Stuporous
 Comatose
Behavior:  Appropriate to Situation
 Combative  Confused  Anxious  Restless  Flat Affect  Uncooperative
 Withdrawn  Other Describe variance: _________________________________________
Oriented to:
 Person
 Place
 Time
Describe variance: ______________________________
Thought Content:  Appropriate to Situation
 Delusions  Obsessions  Somatic Concerns  Depersonalization  Compulsions
 Paranoia/Suspiciousness  Hallucinations
Describe variance: __________________________________________________________________
Thought Process:  Logical  Sequential  Relevant  Goal Directed  Follows Commands
 Disjointed  Irrelevant  Tangential  Circumstantial
Describe variance: __________________________________________________________________
Memory:  Short-term Memory Intact  Long-term Memory Intact
 Memory Not Intact Describe variance: _____________________________________________
Speech:  Clear
 Slurred  Stutter  Difficult to Understand  Laryngectomy  Other ___________
 Aphasia: Type ___________________________________
Describe variance: __________________________________________________________________
Pupil Reaction:  PERRLA
Right:
Left:
Size (circle) 1 2 3 4 5 mm
Size (circle) 1 2 3 4 5 mm
 Brisk  Sluggish  NR  Other __________
 Brisk  Sluggish  NR  Other ___________
Describe variance: __________________________________________________________________
Eyesight:  Normal
 Nearsighted (Myopia)  Farsighted (Presbyopia)  Wears Glasses
 Contacts  Blurred  Diplopia  Glaucoma  Blind:  OD  OS
Describe variance: __________________________________________________________________
Hearing:  Normal
 Hard of Hearing (Presbycusis):  Left Ear  Right Ear  Uses Hearing Aid:  Left Ear  Right Ear
 Deaf:  Left Ear  Right Ear
14
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
Neurological:  MAE
 Motor Disturbances  Seizures  Tremors  Headaches  Numbness  Tingling
 Other: ________________________________________________________________________
Describe variance: _________________________________________________________________
Activity/Exercise
Respiratory:  No Cough
 Cough  Non-productive  Productive Describe (color, characteristics, amount): __________
 Dyspnea:  At Rest  With Exertion  Orthopnea: # of pillows used: _____
Requires HOB increase _____   Tachypnea  Pursed lip
Breathing Pattern:  Non-labored
 Labored  Symmetrical  Asymmetrical  Periods of Apnea
Describe variance: _________________________________________________________________
Oxygen delivery mode:  Room Air  NC  Mask (type) ____________________
 Trach collar  Other _____________________________________
Pulse Oximetry on:
 On Room Air _____ % (result)  O2 _______ type of delivery mode _____% (result)
 Clear/Equal Bilaterally
R
L
Location
Crackles


_____________________________
Rhonchi


_____________________________
Wheezes


_____________________________
Diminished


_____________________________
Absent


_____________________________
Describe variance: _________________________________________________________________
Tracheostomy:  NA
Size: __________________Type: ____________________
Describe Secretions (color, characteristics, amount): _______________________________________
Frequency of Suctioning: _______________________________________________
Breath Sounds:
Chest Tube:  NA
Location: _____________________________
 Water Seal  Suction (amount): ___________________________
 Drainage (color, characteristics, amount): ____________________________________________
Pulse Rate: Apical _____ Radial _____  Pulse Deficit
Describe variance: ____________________________________________________
Heart Rhythm:  Regular  Irregular Describe: ___________________________________________
 Chest Pain  Palpitation
Heart Sounds:  Audible  S1S2
 Murmur  Extra Sounds Describe variance:_________________________________________
EKG Rhythm: ________________________ (per chart)  None in chart, none performed
 Pacemaker Type: __________________
Describe variance: ________________________
Pulses:
(A) Absent (W) Weak
Carotid:
Brachial:
(S) Strong
(D) Doppler
Right _____
Right _____
Left _____
Left _____
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Radial:
Femoral:
Right _____
Right _____
Left _____
Left _____
Pulses (continued):
Popliteal:
Right _____
Left _____
Post Tibial:
Right _____
Left _____
Dorsal Pedis:
Right _____
Left _____
 JVD Describe variance: ___________________________________________________________
Capillary Refill: ___________________________ (# of seconds x 4 extremities)
Activity/Exercise (continued)
Extremeties: Color: WNL for client or describe
UR ______________________________ UL ________________________________
LR ______________________________ LL ________________________________
Temperature H (hot)
W (warm) C (cool/cold)
UR _____ UL _____
LR _____ LL _____
 Calf tenderness:  Right  Left
Describe color change with positional changes: _________________________________
Edema:  None
 Generalized (Anasarca)  Ascites  Dependent  Non-pitting  Pitting
Scale:  +1 (2mm)  +2 (4mm)
 +3 (6mm)
 +4 (8mm)
Location: ______________________________________________________________________________
Activities of Daily Living: (I) Independent (A) Assist (D) Dependent
Feeding___ Bathing___ Grooming___ Toileting___ Dressing___ Other ______________
Describe variance: ________________________________________________________
Mobility:  Ambulatory
 Ambulatory w/ assistance  Transfer w/ assistance  Bed to Chair  Bed rest
 Other __________________________________________________________________________
Describe distance ambulated: _________________________________________________________
Activity Tolerance:  No Problems Ambulating
 Weakness  Fatigue  Dizziness  Light-headed  DOE
Describe variance: __________________________________________________________________
 SCD's  TED's  Other ______________________________________________________
Nutrition/Elimination/Metabolic
Height: __________ (in/cm)
Weight: __________ (lbs/kg)
IBW: __________ (lbs/kg)
General Appearance:  Well-nourished
 Obese  Thin  Cachectic  Other ______________________________________________
Recent Weight:  No Change
 Loss  Gain  Intentional How much? ___________ (lbs/kg) Over what amount of time?
________________________________________________________________
Describe variance: __________________________________________________________________
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Mouth:  Full Dentition
 Loose Teeth  Missing some teeth  Edentulous  Dentures:  Upper  Lower  Partial  Lesions
 Sore Mouth Describe variance: ____________________________________________________
Gums:
 Moist  Pink  Dry  Pale  Hyperplasia  Other: _____________________________
Tongue:  Moist  Pink  Dry  Coated  Other Describe variance: _____________
______________________________________________________________________________
Mucous Membranes:  Moist  Pink  Dry  Pale  Other Describe variance:
______________________________________________________________________________
Nutrition/Elimination/Metabolic (continued)
Type of Diet: ___________________________% Eaten: ______________________________
 Fluid Restriction: __________ cc's
Recent changes in:  Appetite  Eating Describe variance: ____________________
______________________________________________________________________________
 Indigestion  Nausea  Vomiting  Anorexia  Choking with solids
 Choking with liquids
 Difficulty chewing  Difficulty swallowing
Describe variance: ______________________________________________________________
 NG  G-tube  J-tube  G/J-tube  Small feeding tube
 Tube feeding  Bolus  Continuous  Formula (type & strength): ______Rate: ______
 TPN:  Central  Peripheral
Abdomen:  Soft  Non-tender  Flat  Round
 Distended  Gravid  Firm  Rigid  Cramps  Pain  Masses  Gas
Describe variance: _________________________________________________________________
 NG  LIS  LCS
Drainage (color, characteristics, amount): ___________________________________________
Bowel Sounds:  X 4 Quads  Normal
 Hyperactive  Hypoactive  Absent
Describe variance: ______________________________________________________________
Stool:  Continent
 Incontinent  Hemorrhoids  Blood in stool
Ostomies:  Colostomy  Ileostomy  Other _______
Describe stool or ask client to describe (color, characteristic, amount, frequency):
_________________________________________________________________________________________
Last BM: __________________ Usual Pattern: ________________________________
Stoma: Describe (color, size): ______________________________________________
Skin:  Intact  Other
Describe variance: ________________________________________________________
Bladder:  Continent
 Incontinent  Frequency  Urgency  Retention  Dribbling  Burning
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 Dysuria  Anuria  Nocturia  Distention  Other
Describe variance: ________________________________________________________
Urine:
 Clear
 Dark  Cloudy  Bloody  Concentrated  Odorous  Other
Describe urine or ask client to describe (color, characteristics): _______________________________
 Condom catheter  Foley catheter  I/O Catheter How often? _______________
 Suprapubic catheter  Urostomy  Nephrostomy tube  CBI
Describe variance: ________________________________________________________
24 hour I & O: I __________ O __________ cc
 Dialysis Access ___________ Location and type: ____________________________
Comfort/Function
Vital Signs:
Temperature: ________ (site _________)
Respirations: ________________
B/P:  Left arm  Right arm  Other __________
Supine: ______ Sit: _______ Stand:______
_________
Pulse:  Left arm  Right arm  Other _________
Supine: ______ Sit: ______ Stand: _______
_________
Sclera:  White  Jaundiced  Red  Other ____________
Describe variance: ______________________________________________________________
Skin:
 Intact  Color appropriate to client  Warm  Dry
 Pale  Flushed  Clammy  Diaphoretic  Cyanotic  Jaundiced  Dusky  Mottled
 Hot  Cool/Cold  Other _____________________________________________
Describe variance: ________________________________________________________
Turgor:  Elastic  Tenting Describe variance: _____________________________
Rash Scar Wound/Ulcer Lesion Petechiae Ecchymosis Hematoma
Incision(s)
Other
Location ___________________ Description _______________
________________________________________________________________________
________________________________________________________________________
For incision(s):
 Edges well approximated  Open  Inflammation  Redness  Drainage
 Sutures  Staples  Other
Describe size: ___________________________________________________________
 Drain(s) Type: ________________________________________________________________________
Drainage of wounds and drains:
Dressings:
Site
Amount
Color
Characteristics
Location
Type
__________
______________
__________
______________
______________
______________
__________
______________
__________
______________
______________
______________
__________
______________
__________
______________
______________
______________
__________
______________
__________
______________
______________
______________
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Parenteral Access:  None
#1 Site:  IVF (Type) ______________ Rate ______________
 Peripheral lock Location: _________________
 Central (Type) ______________  PICC Line  Peripheral  Other
Type of Access (IV Cath size & length): _______________________________________
 Without redness, swelling, or pain  IV patent  Dressing dry and intact
 Red  Warm  Swelling  Tender  Bleeding  Drainage  Other
______________________________________________________________________________
Describe variance: ________________________________________________________
#2 Site:  IVF (Type) ______________ Rate ______________
 Peripheral lock Location: _________________
 Central (Type) ______________  PICC Line  Peripheral  Other__________
Type of Access (IV Cath size & length): _______________________________________
 Without redness, swelling, or pain  IV patent  Dressing dry and intact
 Red  Warm  Swelling  Tender  Bleeding  Drainage  Other _____
Describe variance: ________________________________________________________
Epidural Access:  None
 Infusion Medication: _____________________________ Rate: ________________
Posture:  Straight/Erect
 Kyphosis  Scoliosis  Lordosis  Other _______________________________
Describe variance: ________________________________________________________
Gait:  Steady
 Unsteady Describe variance: _____________________________________________
Assistive Devices:  None
 Cane  Crutches  Prosthesis  Wheelchair  Other ____________________
Describe variance: _______________________________________________________
Joints:  Full mobility per active ROM  Full ROM per passive ROM
Limited mobility Contractures Limited ROM Pain Swelling Tenderness Stiffness Other
Describe variance: ________________________________________________________
Muscles:  Symmetry
 Weakness  Flaccid  Cramping  Spasms  Other______________________
Describe variance: ________________________________________________________
Strength: (S) Strong (M) Moderate (W) Weak (A) Absent (E) Equal
RUE ____LUE____
 Equal  Unequal
RLE ____LLE____
 Equal  Unequal
Grips: R _____ L _____ Equal  Unequal
Pain:  None
Location: ______________________________________ Rating (1 to 10): _________
Description:______________________________________________________________ Constant 
Intermittent  Aching  Burning  Cramping  Stabbing  Dull
 Throbbing  Heavy  Crushing  Sharp  Other _______________________________
Describe variance: ______________________________________________________________
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Sleep: # of hours: _____________  Rested
 Does not feel rested after sleep  Difficulty falling asleep  Difficulty staying asleep  Naps
Usual Sleep Pattern: _______________________________________________________
 Other ________________________________________________________________
Describe variance: ________________________________________________________
Reproduction/Sexuality
Gender:  Female Completes self-breast exam:  Yes  No
Last mammogram: _____________________
LMP: _________  Post-menopausal Birth Control method: _________ Last Pap Smear: _________
G _____ P _____ A _____ Gyn Surgery: _____________________________
Gyn Problems: ____________________________________________________
Describe Variance: _________________________________________________
 Male
Circumcised:  Yes  No Completes self-testicular exam:  Yes  No
Describe Variance: ________________________________________________
20
Carrington College
LVN to RN Advanced Placement Associate Degree RN Program
RN 225: Advanced Medical Surgical Nursing
Term 1
Clinical Preparation Grading Rubric
Name: _________________________
Date________________
ACTIVITY
EVALUATION
1. Clinical Pathophysiology. Describe the pathologic process of each diagnosis
and state at least one related nursing focus. There needs to be evidence that the
student’s choice of foci came from an understanding of the disorder’s
pathology.
2. Pertinent Medical History & Discharge Plan. Write a paragraph explaining
why patient seek medical help and explain how pertinent historical data
influences his medical diagnosis. Identify appropriate discharge plan.
3. Systems Review. Perform a comprehensive physical examination of the
assigned patient and provide evidence of critical-thinking skills used related to
the patient’s medical diagnosis.
4. Nursing Diagnosis & Daily Nursing Care Plan. Using the information from
your textbook regarding nursing diagnosis and data available from your patient,
write at least three nursing diagnoses and related outcomes and 4 nursing
actions. In the evaluation boxes, state how you would evaluate each specific
nursing diagnosis you have identified. What were your evaluation findings for
your patient?
5. Laboratory Values. Based on the information you have on your patient, make
your interpretation of abnormal values/findings and explain the importance of
the data in relation to your patient. Also be sure to document any labs that are
relevant to your patient’s condition(s).
6. Medication. Based on your patient’s medication administration records,
identify drug actions and the reasons why such medication was prescribed to
your patient.
7. Client Teaching. Using the data presented on your assigned patient and your
understanding of the disease process, choose one topic to teach on and
formulate appropriate teaching plan.
8. Recommendation. Looking at your patient as a holistic being identify
recommendations that will significantly impact the provision of effective,
efficient and safe care.
Legend: P = PASS, NI = NEEDS IMPROVEMENT, F = FAIL
COMMENTS:
21
Carrington College
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RN225, ADV. MED/SURG NURSING-1 CLINICAL
COMPREHENSIVE PHYSICAL ASSESSMENT ASSIGNMENT
Instructions: Student will be assigned a client in the clinical setting and will perform a complete physical
assessment on the client while being observed by the instructor.
Students will be required to write a comprehensive head to toe assessment in narrative form using the
SBAR format. The comprehensive assessment should cover all systems listed in the focused assessment
portion of clinical data collection sheet: neurological, respiratory, cardiovascular, gastrointestinal,
genito-urinary, immune, musculoskeletal, endocrine, nutrition, integumentary and psychosocial. Use a
separate page for this report.
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