Clinicals Template Pack
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By purchasing this material, you agree to the following terms and conditions: you agree that this material and all other media produced by
NurseInTheMaking LLC are simply guides and should not be used over and above your course material and teacher instruction in nursing school.
When details contained within these guides and other media differ, you will defer to your nursing school’s faculty/staff instruction. Hospitals and
universities may differ on lab values; you will defer to your hospital or nursing school’s faculty/staff instruction. These guides and other media
created by NurseInTheMaking LLC are not intended to be used as medical advice or clinical practice; they are for educational use only. You also agree
to not distribute or share these materials under any circumstances; they are for personal use only.
© 2024 NurseInTheMaking LLC. All content is property of NurseInTheMaking LLC and www.anurseinthemaking.com. Replication and distribution of
this material is prohibited by law. All digital products (PDF files, ebooks, resources, and all online content) are subject to copyright protection. Each
product sold is licensed to an individual user and customers are not allowed to distribute, copy, share, or transfer the products to
any other individual or entity, they are for personal use only. Fines of up to $10,000 may apply and individuals will be reported to
the BRN and their school of nursing.
patient background
room #
age
admitting diagnosis/medical history
name
sex
male
code
female
full
DNR
allergies
limited
nka
precaution
droplet
contact
airborne
Assessment
Neuro
Vitals
bp
rr
hr
t
pulse
02
Cardiac
Respiratory
GI / GU
Musculoskeletal
Integumentary
Iv / fluids / drips/ blood
labs
Hgb
WBC
notes
Na
Cl
BUN
K
HCO3
Cr
Glucose
PLT
HCT
PT
Ca
TP
AST
LDH
PO2
ALB
ALT
ALP
PTT
INR
© 2021 NurseInTheMaking LLC
BILI
Head to toe assessment Template
1 inspect
2 palpate
3 percuss
4 auscultate
Level of Consciousness
person
time
place
situation
hair
A&O x
orientation
clean
infestation
diRty
hair loss
sparse
baldness
eyes
awake
drowsy
alert
sedated
restless
confused
vital signs
moist
white
pink
yellow/jaundice
skin
Respiratory rate:
temperature
color
hot
Temperature:
oxygen saturation:
nose
symmetrical
sneezing
Congestion
runny nose
warm
pale
cold
flushed
turgor
moisture
moist
dry
diaphoretic
PAIN
0
1
2
3
LOCATION:
sore/lesions
clamy
tented
no
pain
Mouth
dry
pink
elastic
Skin intact
© 2021 NurseInTheMaking LLC
no
PERRLA
Pupils Equal, Round, Reactive to Light, & Accommodation
Heart rate:
pink
yes
REMEMBER:
Blood pressure:
Mucosa:
drainage
or discharge?
sclera
conjuntiva
description:
INTENSITY:
4
5
6
7
8
9
worst
pain
10
Head to toe assessment Template
ears
abdomen
symmetrical
earwax
hearing devices
discharge
neck
Assess in different order:
1 inspect
2 auscultate
inspection
symmetrical
rounded
3 percuss
bowel sounds
Rlq
absent
normoactive
hypoactive
hyperactive
ruq
absent
normoactive
hypoactive
hyperactive
symmetrical
distended
use of accessory muscles
ascites
luq
absent
normoactive
hypoactive
hyperactive
jugular vein distention
scars
llq
absent
normoactive
hypoactive
hyperactive
upper extremities
lower extremities
grip strength
range of motion
radial pulse
*
normal <2-3 seconds
normal
capillary refill
range of motion
edema
location:
non-pitting
pitting
0
+1
+2
posterior tibial pulse*
capillary refill time (CRT)
heart sounds
grip strength
dorsalis pedis pulse*
capillary refill
rhythm
regular
murmurs
muffled
gallop
bruits
Right 2nd intercostal space
Pulmonic
irregular
wheezing
Left 2nd intercostal space
Auscultate heart sounds
(A, P, E, T, M) with
diaphragm and bell
crackles
ERB’s Point
(S1, S2) Left 3rd intercostal space
Tricuspid
Lower left sternal border 4th
intercostal
regular
Mitral
diminished
other:
rhythm
whooshing
Aortic
breath sounds
clear
+3
chest
other:
© 2021 NurseInTheMaking LLC
4 palpate
Left 5th intercostal,
medial to midclavicular line
pulse chart
*
irregular
Auscultate lung sounds
posteriorly & laterally
0
1+
2+
3+
4+
pulse is absent
diminished
normal
full
bounding, strong
+4
S Situation
room #
age
chief complaint
name
sex
code
male
full
allergies
female
DNR
nka
b background
Past medical hx
a assessment
Neuro
cardiac
gi/gu
limited precaution
droplet
Respiratory
r recommendation
plan of care
© 2021 NurseInTheMaking LLC
airborne
Comorbities
vitals
bp
rr
hr
t
pulse
02
Iv / fluids / drips / Blood
labs
integumentary
Musculoskeletal
contact
medications
orders
discharge
SBAR
Use this script when calling the attending physician
S Situation
Hello, identify yourself & unit.
I’m calling about patient’s name & location.
The reason I’m calling is state the problem.
b background
The patient was admitted on _________
with a diagnosis of ________. State Patient History:
Code status
Meds, Fluids, Allergies
Test results
Past or pending procedures
Consults
Significant health problems
a assessment
I think the problem is resp, cardiac, neuro issue, etc.
because during my assessment I found
provide assessment findings & current vital signs.
OR
I’m not sure what the problem is but the client is
deteriorating, unstable, has changed, etc.
r recommendation
I recommend the patient needs state the
request (more orders, clarification, transfers etc.)
© 2021 NurseInTheMaking LLC
Remember
to read bac
all verbal a k
telephone o nd
rders
concept map template
nursing diagnosis
nursing diagnosis
supporting data
supporting data
goals
goals
patient info
medical history
nursing diagnosis
nursing diagnosis
supporting data
supporting data
goals
© 2021 NurseInTheMaking LLC
goals
Dear future nurse,
You may be stressed, you may feel tired,
and you may want to give up. Nursing school is
hard, there's no doubt about it. Everyone cries,
everyone has meltdowns, and there will be
moments you don't feel qualified for the task at
hand. But take heart, the challenge only makes
you stronger. Put in the work, show up on time,
and find an amazing study group. You got this!
– Kristine Tuttle, BSN, RN
By purchasing and/or downloading this material, you agree to the following terms and conditions: you agree that this ebook and all other
media produced by NurseInTheMaking LLC are simply guides and should not be used over and above your course material and teacher
instruction in nursing school. When details contained within these guides and other media differ, you will defer to your nursing school’s faculty/
staff instruction. Hospitals and universities may differ on lab values; you will defer to your hospital or nursing school’s faculty/staff instruction.
These guides and other media created by NurseInTheMaking LLC are not intended to be used as medical advice or clinical practice; they are for
educational use only. You also agree to not distribute or share these materials under any circumstances; they are for personal use only.
© 2024 NurseInTheMaking LLC. All content is property of NurseInTheMaking LLC and www.anurseinthemaking.com. Replication and
distribution of this material is prohibited by law. All digital products (PDF files, ebooks, resources, and all online content) are subject to
copyright protection. Each product sold is licensed to an individual user and customers are not allowed to distribute, copy, share, or
transfer the products to any other individual or entity, they are for personal use only. Fines of up to $10,000 may apply and individuals
will be reported to the BRN and their school of nursing.
www.anurseinthemaking.com