N241
Pre-Clinical Skills Day
Sim Chart/Clinical prep
COLLEGE OF SAN MATEO
Guide to Clinical Preparation
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
PRE-LAB
Patient Selection:
o Select your patient(s) based on what you are learning in theory and by the
specific guidelines your clinical instructor gives you. Focus on working
with patients who have diagnoses that you are studying in lecture and/or
those who require interventions that you have limited experience with.
Sometimes selecting patients is achieved in preparing for clinical a day in
advance, sometimes it is achieved through working with a select nurse and
choosing patients to care for from that nurse’s case load. Again, this is
determined by your clinical instructor and the “norm” at the clinical
agency.
Data Gathering:
o Use the Quick Prep sheet in this tutorial or one that your instructor directs
you to use and complete all fields.
o Meds:
 List ALL meds; routine and PRN that are given in the 24 hour
period on back or on a separate document (see following pages).
It is vitally important to know the medications that are given
during other shifts as quite often their effects /side effects can
show once the medication reaches its peak. It is also important to
record the times these are given for you own time management. In
addition, know the parameters (vital signs or lab values) that may
prevent you from administering the medication.
o Complete the pathophysiology – the concept map approach is really great
to use as a study tool and it helps you to form a basic understanding in
planning care for the patient.
o Determining the priority assessments
 Your patient load is going to increase this semester and it will not
be possible to complete a complete head to toe physical assessment
on each patient at the beginning of your shift. With that think
about what are the top assessments you NEED to complete on each
patient.
 From information you gather in report, documentations and from
the patient you can strategize what assessments are important.
 Justify why you are selecting the particular assessment, what you
would expect to find and what other data is important. See the
example that follows:
Example: Patient has an admitting diagnosis of CHF exacerbation.
Chronic conditions for which the patient is being managed include:
COPD, Diabetes, A-fib and an ongoing venous stasis ulcer.
IDENTIFY the TOP 3 PRIORITY
ASSESSMENTS and Why you selected
this.
What do you expect to find?
What will you do to gather more
information?
1. Cardiovascular (patient has an
exacerbation of CHF. Has a history of
A-fib and current venous stasis
ulcers)
Possible abnormal heart sounds
and irregular heart rate. Maybe
adventitious lung sounds and
peripheral edema. Poor
circulation to extremities
Complete a CV assessment.
Ask the patient about activity
intolerance. What
medications are used? Review
past VS data and records for
weight. Evaluate patient’s
diet.
2. Respiratory (patient has COPD
and with the CHF may have
respiratory issues)
Adventitious lung sounds. O²
therapy. SOB
Complete a respiratory
assessment. Look over past
o² sat records. Does the
patient need teaching on
energy conservation and
better breathing techniques?
3. Integumentary (Current venous
stasis ulcers)
Expect to find these in the lower
extremities
Check the latest wound care
notes. What is the current
treatment. How does the
patient manage these at
home?

o Select a nursing problem based on the data you have collected in your
prep and use it to complete the Nursing Care Plan in Sim Chart if it is
applicable.
Record other important data on the quick prep sheet and your “nurse’s brain”
sheet that will need to be inputted on Sim Chart (i.e., vital signs, assessment
findings, potential discharge problems)
COLLEGE OF SAN MATEO NURSING
CLINCIAL QUICK PREP **SECOND YEAR NURSING STUDENTS
STUDENT:
DATE: __/__/____
Sim Chart Patient 
PATIENT:_______ RM#:________ AGE:________ GENDER:_____ Admit/Surgical DATE:_____________
Allergies: _________ CODE STAT:_______ RELIGION/CULTURE/SPECIAL NEEDS: _____________________
ADMITTING DX:_____________________________ Chronic Conditions: ___________________________
FALL RISK; SKIN INTEG:  OTHER SAFETY ISSUES __________________________________________
BATHING ___________
ACTIVITY ____________
DIET ___________ INTAKE/OUTPUT  DAILY WEIGHT
Blood Gluc.   FOLEY  OTHER RAINS/TUBES:_______________________________________________________
O2 (order type)_____________________Treatments and Therapies (times):__________________________________
Scheduled Diagnostics; list Indication and time: _______________________________________________
LABS to be drawn __________________________________ Labs out of range to monitor: ______________________
IV FLUID_____________ RATE or Intermittent _______ IV Site location and Assessment _____________
IDENTIFY the TOP 3 PRIORITY
ASSESSMENTS and Why you selected
this.
What do you expect to find?
What will you do to gather more
information?
1.
2.
3.
IDENTIFY THE PRIORITY NURSING PROBLEM AND GOAL(S) FOR THE DAY(S)
Priority Nursing Dx.______________________________________________________________________
STG: Goal for the day(s)_________________________ LTG: Goal for Discharge ______________________
Interventions: ______________________________
______________________________
__________________________
__________________________ __________________________
Identify a Teaching Need (align with care plan): ________________Teaching Goal: ___________
Patient residence prior to hospitalization? _____________________ Patient disposition (will be
discharged to: ____________________ Anticipated DC needs: ________________________________
Any additional information:
You will need to create a Medication List from the ENTIRE MAR (not just “your shift, ALL) that
includes:




Medication Name (focus on the generic)
Dose, route, time (for routine) and intervals (PRN)
Indication – Why is the patient receiving the med? You MUST relate it to the patient’s medical
issue (e.g., Gabapentin – for peripheral neuropathy)
List important nursing considerations – these include
o PARAMETERS ARE A MUST (e.g., hold for BP<; Call MD if…)
o Know what lab values might need to be checked prior to giving med
o What do you need to teach the patient about this drug?
o What adverse side effects are to be observed?
o What precautions are important to reinforce with the patient?
o If it is an IVP or IVPB INDICATE THE RATE OF INFUSION (i.e., mL/hr or minutes to
push). Note incompatible fluids
o If you are familiar with a medication you can just list the name, dose, route and time.
However, be prepared to discuss the indication and necessary nursing considerations
with your clinical instructor and or RN
Copy and paste this to your own word document – add more rows if necessary
MED
Generic and
Trade
DOSE, ROUTE,
TIME
INDICATION
Be specific and
relate it to the
patient’s medical
profile
NURSING CONSIDERATIONS
Copy and paste this to your own word document – add more rows if necessary
LAB TEST
NORMAL RANGE
(male/female and
elderly
considerations)
WHY IS IT ABNORMAL (relate
this to the patient’s
current/past health history
and/or medication history)
NURSING CONSIDERATIONS
(What is the nurse most
concerned with? What
needs to be
assessed/evaluated?)
Copy and paste this to your own word document – add more rows if necessary
DIAGNOSTIC TEST
INDICATION
PRE-TEST
POST-TEST NURSING
(provide a definition)
PREPARATION
CARE
PATHOPHYSIOLOGY CONCEPT MAP
ETIOLOGY (List ALL possible causes and HIGHLIGHT what may have caused your patient’s diagnosis)
DISEASE PROCESS and DEFINITION (In your OWN words)
CLINICAL MANIFESTATIONS (List ALL possible signs/symptoms and HIGHLIGHT the ones your patient exhibits)
MEDICAL (other disciplines)
TREATMENTS/INTERVENTIONS
(List ALL – HIGHLIGHT your patient’s)
NURSING CARE
(List ALL – HIGHLIGHT your patient’s)
WORST CASE SCENARIO
(Describe the signs and symptoms that indicate the situation is worsening)
SIM CHART GUIDELINES
Directions: Complete 5 Sim Charts total during the N241 time frame
Guidelines:
o Patient selection:
o You must complete 2 Respiratory related prior to test #1
o You must complete 2 Cardiac related prior to test #2
o You must complete 1 either Renal related or Hematologic related prior
to the final exam
o Select patients with active problems that are either admitting diagnoses or
are a chronic condition.
o Check the box at the top of the Quick Prep sheet to indicate you are
using that patient for Sim Chart purposes
o Sections: Each Sim Chart will include
o A Patient Profile
 This must be completed in order to proceed to the subsequent
sections. Include the code status, allergies and diet
o Pre-clinical Manager (pathophysiology, meds, labs and diagnostics)
o Patient Charting
 Admission history
 Discharge planning
 Systems Assessment (focus on the top 3)
 System Nursing Interventions (aligned with the Systems
Assessment)
 Basic Nursing Care
 Any Special Charts, wounds, IVs, Drains/Tubes and Ostomies
 Vital Signs
 Care plan (2 top problems)
 Teaching plan
Complete all SEGMENTS in SIM CHART following these specific directions
SEGMENT 1 = PATIENT PROFILE ** You will not be able to go forward
without doing this.
 Complete these fields: Code Status, Diet and Allergies
SEGMENT 2 = PRE-CLINICAL(Pathophysiology, Meds, Labs and Diagnostics)
FOLLOW THESE DIRECTIONS!!!
Complete the three areas of Pathophysiology as directed below
o Under pathophysiology:
 Include a definition in your own words, the patient’s likely
etiology and the patient’s clinical manifestations.
o Under Therapeutic Regimen:

Include the medical and nursing interventions and separate the
two:
 What are the related MD to order, treatments etc..
 What are the nurses doing to care for this patient?
 Who else may be on the treatment team? Speech
therapist? Pharmacist? Physical therapist? What is
their role in helping the patient?
o Under Current Health Problems and Related Functional Changes:
 Discuss the problems the patient has or had experienced with the
selected pathophysiology and how it impaired or impairs the
patient’s daily function.
 MEDICATIONS
o Include only the medications that are related to the diagnosis (e.g., if it
is COPD – list the respiratory therapy medications and all that are related
from the routine and PRN medications)
o DO NOT COPY AND PASTE FROM A RESOURCE!!
o Complete the following fields
 The top section from Medication to date ordered (may use
current date)
 Therapeutic Effect
 What is the intended action FOR THIS PATIENT?
Example: The medication may be classified as a narcotic
(i.e., morphine) but in this case it is used to relax breathing.
 Contraindications
 Complete if applicable
 Side /Adverse Effects
 Include any SIGNIFICANT effects; you do not need to
include the usual SEs expected of most drugs – just those
the nurse needs to know
 Life Threatening Considerations
 This will be highlighted in red, include those that are
actually life threatening – i.e., Malignant Hypertention
 Recommended Dose Range
 Provide the range and indicate if it is appropriate for your
patient
 Hint: Some are high dosages because it is a loading dose
vs. a maintenance dose
 Nursing Interventions
 List PARAMETERS here; VS and/or lab values
– Do you need to take a BP prior?
– What parameter indicates to hold the med? i.e.,
Hold for a pulse < 60
– Should you check a lab value? i.e., if potassium is
> 5.2, you should call the MD before giving that
extra potassium supplement
 LABORATORY VALUES
o List only those related to the diagnosis.
o Complete all fields:
 Definition and Description:
 What does the test measure? What does the high or low
value indicate?
 Significance of the test being ordered for this patient:
 Why is it ordered?
 DIAGNOSTIC TESTS performed to diagnose the condition
o Definition and Description of the Test:
 What is the test and how is it performed; i.e., Gastro-Intestinal
Endoscopy; performed under conscious sedation where an
endoscope is inserted through the mouth  esophagus….
 Include what the nurse needs to know about this test
 Special preparation
 Patient teaching
 Monitoring condition after the test
o Significance of the Test Being Ordered for this Patient;
 Why is this patient having this test? Relate it to the patient’s
diagnosis
o Significant Findings and Results:
 What was found?
** If there are no lab values or diagnostic tests related to the condition you are focusing on in
the pathophysiology then indicate that to your instructor in the Pre-Clinical Manager
Pathophysiology section **
NURSING CARE PLAN use the pull down menu in Sim chart and/or add your data from
other resources
 Select Medical Diagnosis
 Select the priority Nursing Diagnosis (Problem) – one only. You may “Add” a
new one if the list provided does not include one you were thinking is more
appropriate.
 Select if Actual or Potential
 Complete the Related To – “Add” if necessary
 Complete Evidence By - “Add” if necessary
 Select a Minimum of two Expected Outcomes -“Add” if necessary and be sure
to include measurement and time frame
 Select a Minimum of two interventions per each outcome - “Add” if necessary
 Once you have saved the care plan you may enter comments and evaluate the
goals
Patient Charting – Include the following
 Admission history
 Discharge planning
 Systems Assessment (focus on the top 3)
 System Nursing Interventions (aligned with the Systems
Assessment)
 Basic Nursing Care
 Any Special Charts, wounds, IVs, Drains/Tubes and Ostomies
 Vital Signs
 Care plan (2 top problems)
 Teaching plan