1 of 28
Clinical Packet
Medical-Surgical Nursing
Part II
Contents:
Clinical Limitations
Medication Knowledge Base Requirements
Concept Mapping for Clinical Care Planning
Care Plan Instructions and Guidelines
Evaluation Criteria for Nursing Care Plans
Draw a Diagram of Concept Mapping with Patient Profile Form
Nursing Care Plan Forms
Draw a Diagram of Concept Map for Overall Clinical Care Planning and
Relationship between Diagnoses Form
Student Signature Form
Revised 12-22-2009 by Shu-Yi Wang & Lyman Spaulding
2 of 28
LIMITATIONS TO CLINICAL PRACTICE
During this clinical rotation, students may, with preceptors’ consent and supervision, assume
responsibility for all the nursing activities within the preceptors’ roles. The following are
exceptions to this rule.
Students may not do the following:
1. Witness any consent forms.
2. Administer any IV (intravenous) push medications without direct supervision by a
Registered Nurse.
3. Perform any task that requires certification or advanced instruction (e.g., arterial blood
gas (ABG) puncture, chemotherapy, removal of central venous catheters,
interpretation/monitoring of EKGs).
4. Take physician orders either verbally or by phone.
5. Transcribe physician orders.
6. Initiate invasive monitoring.
7. Regulate epidural analgesia.
8. Remove epidural catheters.
9. Remove surgically inserted drains and/or tubes (e.g., chest tubes, Jackson-Pratt drains,
Hemovac drains)
10. Solely monitor patient during and following conscious sedation.
11. Witness wasting or the sign out controlled medications in Accudose, Pyxis, or Meditrol
medication delivery systems.
12. Perform end of shift controlled medication count (if applicable).
13. Have controlled medication keys in their possession (if applicable).
14. Verify blood products and/or witness blood administration forms.
15. Perform any invasive procedure on each other in any setting. (i.e., injections,
catheterization, IV starts).
16. Interventions that the facility restricts the student from performing.
17. Any skill/procedure that has not been covered in a nursing lab.
18. Medication administration should not occur in NRS 105 Foundations of Nursing.
19. Any task outside the Registered Nurse’s scope of practice as identified by facility.
Any questions regarding specific procedures or responsibilities should be directed to the Denver
School of Nursing faculty. Students are expected to maintain standards of care of the facility and
function within the scope of their knowledge, skills, and abilities.
3 of 28
MEDICATION KNOWLEDGE BASE

Drug required knowledge is mandatory for each medication to be administered for each
assigned patient.

If you can memorize and retain information without writing it down, you may do this, but
you may not pass medications without this knowledge at hand – use of reference materials at
the cart side or at the PIXIS is time prohibitive and must be a rare back-up system.

Student must be prepared to recite required knowledge base (as outlined below) at med-cart
or PIXIS as requested by instructor.

Using a drug knowledge tool is useful in review for future clinical rotations and for NCLEX
review and to prepare for different patients.

Medication knowledge base MUST include the MINIMAL information as reflected below:
Medication Knowledge Base:
Pt. initials
Rm #
Name of Drug
Generic: Aspirin/acetylsalicylic acid – Brand: Ecotrin®
Classification
Antipyretic, non-narcotic analgesic. Anti-inflammatory, antiplatelet
Use for this patient
Reduce risk of MI by prevention of clots
Prevention of clots due to anti-platelet action or reduces fever by action on
hypothalamus heat-regulating center and vasodilation or reduces inflammation and
pain by blocking prostaglandin synthesis,
Varies dependant on use from 80mg qd to 1.3G q6h
80 mg qd for antiplatelet action
N/A
Hypersensitivity, bleeding disorders, use caution in pregnant/breastfeeding
women.
Tinnitus, hearing loss, N&V, bruising, bleeding
Monitor hgb, hct, serum salicylate level (long-term use)
1. Give with food, milk
2. Monitor for abdominal pain or bleeding
3. Enteric-coated absorbed more slowly but less bleeding risk
4. Check with prescriber for use with OTC or other Rx drugs
5. Advise patient to report any increased bleeding, bruising, or nose bleeds
6. Advise patient to take with food
Weekly skin checks for increased bruising
Action – as applies to
this patient
Dosage Range
Patient Dosage
IV rate
Contraindications
Side Effects
Labs
Nursing Interventions/
Patient Teaching
Must do
* ‘Must do’ could be ‘Take pulse’ for drugs affecting heart rate or rhythm, ‘Take BP’ for drugs
affecting BP, Check K+ before administering for potassium supplements, Check BG for insulin
or other drugs affecting BG, etc.
4 of 28
CONCEPT MAPPING FOR CLINICAL CARE PLANNING
Using the concept map synthesizes relevant data such as diagnoses, signs and symptoms, health
needs, learning needs, nursing interventions, and assessments. Analysis of the data begins with
the recognition of the interrelatedness of the concepts and a holistic view of the client's health
status as well as those concepts that affect the individual such as culture, ethnicity, and
psychosocial state.
Example (King & Shell, 2002)
5 of 28
CONCEPT MAP FOR CLINICAL CARE PLANNING AND RELATIONSHIPS BETWEEN DIAGNOSES
Note: Straight line =related to nursing diagnosis; dotted line=relationship between diagnoses
Reference
Critical thinking strategies: Concept mapping. Retrieved June 25, 2009, from http://cord.org/txcollabnursing/onsite_conceptmap.htm
6 of 28
NURSING CARE PLAN GUIDELINES AND INSTRUCTIONS









In order to maintain consistency within the DSN nursing program, the following guidelines
must be adhered to when writing nursing care plans.
ADPIE (assessment, nursing diagnosis, plan, interventions, and evaluation) is used to teach
the nursing process.
Students will be taught the relationship between NANDA (North American Nursing
Diagnosis Association), NIC (Nursing Interventions Classification), and NOC (Nursing
Outcomes Classification).
Beginning in Foundations of Nursing, students will be taught, in detail, to use this format
presented here. In addition, they will be instructed on how to use their nursing care plan
reference.
This format will be used for clinical rotations and other educational activities/assignments in
foundations of nursing, medical-surgical nursing, and pediatrics.
Please note that content mapping may be used as a teaching tool but cannot be used instead
of the nursing care plan presented in this document.
Three to five care plans (which include nursing diagnosis statement, plan, interventions,
and evaluation), based on the student’s history and physical which is recorded on the “Patient
Profile Database” form, are required for each patient you cared for during the clinical
rotation. One nursing diagnosis should be addressed on psycho-social-cultural aspect.
The data form can be found later in this packet.
Each care plan needs to be on a separate “Nursing Care Plan Form.” These forms can be
found on later in this packet.
Please make copies of the data and nursing care plan forms and/or keep the electronic file
that has been sent to you.
Assessment


Assessment should be recorded on the “Patient Profile Database” form
The assessment is the basis for the nursing diagnosis statement
Nursing Diagnosis Statement
General format for an actual diagnosis:
Nursing diagnosis related to X as evidenced by Y and Z.
General format for a potential or “at risk” diagnosis:
Nursing diagnosis related to X.
7 of 28
The nursing diagnosis statement is written using the PES (problem, etiology,
signs/symptoms) format:

Problem
 Nursing diagnosis

Etiology or cause of problem
 The "related to" portion of the statement
 There should only be one cause stated per nursing diagnosis, because each etiology
may have a different set of goals, outcomes and interventions, although the problem
or nursing diagnosis may be the same.
 The etiology cannot be a medical diagnosis

Signs & symptoms (also called defining characteristics)
 The "as evidenced by" portion of the statement
 These are determined through your assessment of the patient
 Two objective or subjective s/s must be listed per statement
 For potential or “at risk” diagnoses, signs and symptoms should not be included in the
nursing diagnosis statement
EXAMPLE OF A NURSING DIAGNOSIS STATEMENT
Medical diagnosis: Stroke
Nursing diagnosis statement: "Immobility related to motor track dysfunction as evidenced by
weakness and lack of coordination."
Notice the related to portion did not say stroke, rather it stated the pathophysiology behind the
medical diagnosis that is causing the problem.
Plan or Goals & Outcomes Statement
General guidelines:
 The goals and outcomes statement make up the plan portion of the nursing process
 The goal and outcomes statement should be written as one statement
 Each nursing diagnosis should have two goals
 The goal and outcome should be prioritized within the care plan
 The goal is patient and/or family focused and should be mutually determined by the nurse
and the patient and/or family
 The goal should not be the goal of the nurse
 The goal may be short-term (hours to a week) or long-term (> 1 week)
8 of 28
The goal and outcome statements are written using the SMART (specific, measurable.
attainable, realistic, time-specific) format
 Specific: What needs to be accomplished?
 Measurable: How will the nurse, patient, and/or family know that the goal has been met?
 Attainable: Can the goal be met with the resources available?
 Realistic: Does the patient and/or family have the physical, emotional, and mental
capacity to meet the goal?
 Time-specific: When will the goal be achieved by?
EXAMPLES OF GOAL AND OUTCOME STATEMENTS
For the stroke patient . . .
Goal and Outcome #1: Patient will perform ROM exercises each hour during the shift.
.
Goal and Outcome #2: Patient will ambulate from bed to door twice by the end of shift
Interventions with Rationale
General guidelines:
 There should be at least two interventions with rationale for each goal statement.
 The interventions can be strictly nursing based or collaborative (e.g., medication for
nausea as ordered by MD) in nature
 Interventions need to be specific: what, when, how much, and how often
 Each intervention should be referenced
EXAMPLES OF INTERVENTIONS WITH RATIONALE
For the stroke patient . . .
Goal/outcome #1 interventions w/ rationale:
1) Educate patient about importance of ROM exercises. Rationale: If patient understands the
importance of ROM exercises (to maintain and increase strength), the patient is more likely to
participate in exercises (Potter & Perry, p. 4).
2) Assist patient with ROM exercises while teaching him how to perform ROM exercises.
Rationale: Patient needs to be instructed on how to perform ROM exercises, and performing
the exercises while instructing the patient will solidify his understanding so he can perform
exercises on his own (Potter & Perry, p. 5).
Goal/Outcome #2 interventions w/ rationale:
1) Determine amount of assistance needed to get patient out of bed and ambulate Rationale:
Weakness and lack of coordination can cause the patient to be off balance which could put
him at risk for a fall.
2) Clear walkway of hazards. Rationale: Patient is at risk for falls so clearing hazards will
provide a safe path to ambulate (Potter & Perry, p. 3).
9 of 28
Evaluation
General guidelines:
 Evaluation occurs to determine whether or not the goals were met
 Evaluation should occur at the end of the shift.
 If the goal was not met or partially met, the student should discuss why it was not met
and state what should be done differently, if anything.
EXAMPLE OF EVALUATION OF GOALS
For the stroke patient . . .
Evaluation of Goal #1: Patient understood the need to perform ROM exercises, but will need
continued reinforcement until he is able to perform exercises independently. Will continue with
the current plan.
Evaluation of Goal #2: Patient exceeded goal by walking 4 times. Will modify current plan by
increasing distance of walk (from bed to nurses’ station).
References
Ackley, B, & Ladwig, G. (2007). Nursing diagnosis handbook: A guide to planning care (8th
ed.). St. Louis: Evolve Resources.
class)
Potter, P. & Perry, A. (2005). Fundamentals of nursing. (6th ed.) . St Louis: Elsevier
Top Achievement. Creating S.M.A.R.T. goals. Retrieved March 25, 2008 from
http://www.topachievement.com/smart.html
10 of 28
Sample Nursing Care Plan
Student Name: Sally Jones
Date: 3/17/08
Patient (initials only): R. N.
Patient Medical Diagnosis: Stroke
Nursing Diagnosis (use PES format): Immobility related to motor track dysfunction as evidenced by weakness and lack of coordination.
Assessment Data
(Include at least three-five subjective
and/or objective pieces of data that lead
to the nursing diagnosis)
Goals & Outcome
(Two statements are required for each
nursing diagnosis. Must be Patient
and/or family focused; measurable;
time-specific; and reasonable.)
Nursing Interventions
(List at least two nursing or
collaborative interventions with
rationale for each goal & outcome.)
Rationale
(Provide reason why intervention is
indicated/therapeutic; provide
references.)
Outcome Evaluation & Replanning
(Was goal(s) met? How would you
revise the plan of care according the
patient’s response to current plan of
care?)
1. +2 weakness on left
upper and lower
extremity
Statement #1: Patient will perform ROM
exercises each hour during the shift.
1. Educate pt about importance of ROM
exercises. Rationale: If pt understands the
importance of ROM exercises (to maintain
and hopefully increase strength), the pt is
more likely to participate in exercises (Potter
& Perry, p. 4).
1. If patient understands the important of
ROM exercises (to maintain and hopefully
increase strength), the patient is more likely
to participate in exercises (Potter & Perry, p.
4).
Outcome #1: Pt partially met goals. He
was open to and understanding of the need
to perform ROM exercises, but he still needs
guidance in how to perform. Will continue to
with current plan.
2. Assist pt w/ ROM exercises while
teaching him how to perform ROM
exercises.
2. Inability to walk without
assistance (patient
shuffles when walks and
gets confused as to
which leg needs to
move to propel forward)
Statement #2: Patient will ambulate from
bed to door twice by the end of shift.
2. Pt needs to be instructed on how to
perform ROM exercises, and performing the
exercises while instructing the patient will
solidify his understanding so he can perform
exercises on his own (Potter & Perry, p. 5).
1. Determine amount of assistance needed
to get patient out of bed and ambulate.
1. Weakness and lack of coordination can
cause the pt to be off balance which would
put him at risk for a fall. Determining level if
assistance needed before trying to assist out
of bed and ambulate will prevent a fall for the
patient (Potter & Perry, p. 2).
2. Clear walkway of hazards. Pt is at risk
for falls so clearing hazards will provide a
safe path to ambulate (Potter & Perry, p. 3).
2. Pt is at risk for falls so clearing hazards
will provide a safe path to ambulate (Potter &
Perry, p. 3).
Outcome #2: Patient exceeded goal: he
walked 4 times. Wil modify plan to increase
distance (to nurses’ station).
11 of 28
EVALUATION CRITERIA FOR NURSING CARE PLANS (NCP)
At least one nursing care plan (or update of care plan) will be evaluated per week on a pass-fail basis – fails will be
required to revise until final care plan is adequate
DAY 1 CARE PLAN IS A DRAFT – FACULTY TO REVIEW FOR SUGGESTIONS TOWARD FINAL PRODUCT –
PASS-FAIL EVALUATION WILL BE ON DAY 2 CARE PLAN
Patient Profile Database Form (24%)
______Assessment: All subjective and objective data are documented on form (10%)
______Pathophysiology: Should be based on the medical diagnosis (6%)
______Laboratory Data: Noted as normal or abnormal and reason abnormal (8%)
Drug Cards (10%)
______ Medications:
________Medications with administration time should be listed on the “Patient Profile Database”. (1%)
_______Exhibit knowledge required at time of setting up medications for administration (9%)
Nursing Care Plan Forms (66%)
______Nursing Diagnosis Statements: (15% points possible-see breakdown below)
_____Three statements are written (1 %/statement for a total of 3 possible points)
_____Only NANDA-approved nursing diagnoses are used (1 %/statement for
a total of 3 % possible)
_____ Statements are written in PES (for actual diagnoses) or PE (for potential or “at risk”
diagnoses) format (1%/statement for a total of 3% possible)
_____Diagnosis is supported by assessment data (1%/statement for a total of 3% possible)
_____ Nursing diagnoses are listed from highest to lowest priority. Life threatening
diagnoses (e.g. ABCs, infection, etc.) come first, then safety, then all others.
Usually existing problems come before “risk for" problems (1%/ statement for a
total of 3% possible)
______Plan: Goals and Outcomes Statements: (12 % possible-see breakdown below)
_____Two statements are required for each nursing diagnosis statement (2 %/ statement for a total of 6% possible)
_____Statements are prioritized (1%/set of goals for a total of 3% possible)
_____Statements are written in SMART format (1 %/ statement for a total of 3% possible)
______ Nursing Interventions with Rationale: (24 % possible-see breakdown below)
_____ Each goal has two interventions (1%/goal for a total of 8% possible)
_____ Each intervention has a rationale with a reference (1%/goal for a total of 8% possible)
_____ Statements are specific (what, when, how much, how often) (1% per goal for total of 8% possible)
______Evaluation: (5 %)
State if goal has been met; if not met or partially met, discuss whether will continue or modify plan (5%)
______Concept mapping for overall clinical care planning and relationship between diagnoses (10%)
Final Grade: ___________ Date:____________ Instructor signature: __________________________
Evaluation minimum 85% required for a rating of ‘pass’, if not, student must rewrite care plan
12 of 28
PATIENT PROFILE DATA FORM
Student Name:
Date of Care:
Patient Initials:
Age:
Gender: Male  Female 
Admission Date:
Reason for Hospitalization:
Medical Diagnoses:
Surgical Procedure(s):
Date:
Pathophysiology/Description of any current medical diagnosis or surgical procedure (Continue on back of
this page, no less than 3-5 sentences per diagnosis/procedure, include symptoms to watch for and any
current treatments pertinent to the patient)
13 of 28
Advance Directives
Living Will:  yes  no
Do Not Resuscitate Order (DNR)  yes  no
Medical Durable Power of Attorney:  yes  no (If yes, relationship?)
Laboratory Data
Write normal value range, exact value for patient, and indicate if this is normal, high, or low; if abnormal state
pathophysiology resulting in abnormal value – students MAY NOT use the term WNL or chart by exception on
this form.
White Blood Count (WBC)
Potassium
Differential (Diff)
Blood Glucose
Hemoglobin (HGB)
Glycohemoglobin
Hematocrit (HCT)
Cholesterol
Platelets (PLT)
Low-density Lipoproteins
Prothrombin Time (PTT)
Urine Analysis
International Normalized Ratio (INR)
Activate Partial Thromboplastin time (APTT)
Other abnormal data related to patient’s situation:
Description of overall data analysis
14 of 28
Diagnostic Tests
Chest X-Ray
EKG
CT/MRI
Other:
Medications (Use back of sheet if more space is needed; required medication knowledge for each of these
drugs must be present to pass medications)
Medication/Time of Administration/Reason given
Medication/Time of Administration/Reason given
medication
medication
Allergies
Last pain medication given
Where is the pain?
Pain rating on 0-10 scale
Treatments (Eg: PT, OT, RT, etc)
Treatment
Treatment
Support Services
Consultations
Other:
15 of 28
Diet/fluids
Type of diet:
Restrictions:
Appetite:
Fluid intake:
Tube feedings (type and rate)
Problems swallowing, chewing,
dentures
Needs assistance with feeding
Nausea or vomiting
Over-hydrated or dehydrated
Other:
Intravenous Fluids
Type and rate
Site(s)
IV dressing dry, no edema or redness at site
Other:
Elimination
Last bowel movement (LBM)
Catheter  yes  no
Type:
24 hour urine output:
Circle problems that apply:
Bowel
Urinary
Constipation
Hesitancy
Diarrhea
Frequency
Flatus
Burning
Incontinence
Odor
Other:
Activity
Ability to walk/Gait
Type of activity orders
Assistive Devices
Fall risk assessment rating
Side rails (number)
Weakness
Restraints  yes  no
Physical Assessment Data
BP
TPR
Height
Weight
16 of 28
Write exactly what you see/hear/etc. and indicate if this is normal, abnormal, hyper, or hypo; if abnormal then
state pathophysiology resulting in abnormal assessments – students MAY NOT use the term WNL or chart by
exception on this form.
Neurological/Mental Status ____
LOC A&OX3, Confused
Motor ROM X 4 extremities
Sensation X 4 extremities
Pupils PERRLA
Sensory deficits (hearing, vision, taste, smell, sensation)
Other:
Musculoskeletal System _____
Bones, joints, muscles (fractures, contractures,
arthritis, spinal curvatures, etc.)
Extremity circulation checks (pulses, temperature,
sensation, edema)
TED hose, Compression devices
Cast/splint/collar/brace
 yes  no Type:
Other:
Cardiovascular system ____
Pulses
Capillary Refill
Neck Vein Distention
Edema (degree, pitting,
location)
Sounds: S1, S2, regular/irregular
Chest pain
Other:
17 of 28
Respiratory System ____
Cyanosis  yes  no
Location:
Breath Sounds: clear, rales,
wheezes, location
Depth, rate, rhythm
Use of accessory muscles
Sputum: color, amount
Cough: productive,
nonproductive
Breath Sounds: clear, rales,
wheezes, location
Use of O2: nasal cannula, mask,
trach collar
Flow rate of O2
O2 humidification
 yes  no
Other:
Pulse Oximetry: ____ % oxygen
saturation
Smoking History
 yes  no
Gastrointestinal System ____
Abdominal pain, tenderness, guarding, distention,
soft, firm
Bowel sounds X 4 quadrants
NG tube: describe drainage
Ostomy: describe stoma site & drainage
Other:
Skin and Wounds ____
Color, turgor
Rash, bruises
Describe wound(s) location, size
Edges approximated yes no
Drains (type & location)
Characteristics of drainage
Dressings (clean, dry, intact)
Sutures, staples, steri-strips,
other
Risk for decubitus ulcer assessment
rating
Other:
18 of 28
Eyes, Ears, Nose, Throat (EENT) ____
Eyes: redness, drainage, edema, ptosis
Ears: drainage
Nose: redness, drainage, edema
Throat: pain, edema
Other:
Psychosocial and Cultural Assessment
Religious preference
Marital status
Health care benefits and insurance
Occupation
Emotional state
Other:
Additional information to obtain from clinical units specific to patient diagnosis
Standardized fall risk
assessment
Pressure Ulcer (Skin)
Risk assessment
Standardized Nursing
Care Plans
Patient Education
Materials
Advanced Assessment (Gordon 11 Functional Assessment)
Health Perception-Health Management Pattern
Objective
1. Mental Status (indicate assessment with a )
a. Oriented__ Disoriented__
Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__;
b.Sensorium
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__Cooperative__ Combative__ Delusional__
c. Memory
Recent: Yes__ No__; Remote: Yes__ No__
2. Vision
a. Pupil size: Right: Normal__ Abnormal__; Left: Normal__ Abnormal__
b. Pupil reaction: Right: Normal__ Abnormal__; Left: Normal__ Abnormal__
3. Hearing
a. Hearing aid: Yes__ No__
4. Cerebellar Exam (Balance, gait, coordination, etc.)
19 of 28
Normal__ Abnormal__ Describe:______________________________
_________________________________________________________
5. Reflexes: Normal__ Abnormal__ Describe: ______________________
_________________________________________________________
6. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
_________________________________________________________
_________________________________________________________
7. General appearance:
a. Hair: __________________________________________________
b.Skin: __________________________________________________
c. Nails: _________________________________________________
d.Body odor: _____________________________________________
Nutritional-Metabolic Pattern
Objective
1.Skin examination
a. Warm__ Cool__ Moist__ Dry__
b.Lesions: No__ Yes__ Describe: _______________________________
c. Rash: No__ Yes__ Describe: _________________________________
d.Turgor: Firm__ Supple__ Dehydrated__ Fragile__
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__
Other____________________________________________________
2.Mucous Membranes
a. Mouth
i. Moist__ Dry__
ii. Lesions: No__ Yes__ Describe: __________________________
iii. Color: Pale__ Pink__
iv. Teeth: Normal__ Abnormal__ Describe:____________________
v. Dentures: No__ Yes__ Upper__ Lower__ Partial__
vi. Gums: Normal__ Abnormal__ Describe:____________________
vii. Tongue: Normal__ Abnormal__ Describe:___________________
b.Eyes
i. Moist__ Dry__
ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__
iii. Lesions: No__ Yes__ Describe:___________________________
3.Edema
a. General: No__ Yes__ Describe:_______________________________
4.Thyroid: Normal__ Abnormal__ Describe: _________________________
5.Jugular vein distention: No__ Yes__
6.Gag reflex: Present__ Absent__
7.Can patient move easily (turning, walking)? Yes__ No__
Describe limitations: __________________________________________
8.Upon admission, was patient dressed appropriately for the weather?
Yes__ No__ Describe: ________________________________________
Elimination Pattern
20 of 28
Objective
1.Auscultate abdomen:
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2.Palpate abdomen:
a. Tender: No__ Yes__ Where?_________________________________
b.Soft: No__ Yes__; Firm: No__ Yes__
c. Masses: No__ Yes__ Describe: _______________________________
d.Distention (include distended bladder): No__ Yes__ Describe: _______
_________________________________________________________
e. Overflow urine when bladder palpated? Yes__ No__
3.Ostomy present: No__ Yes__ Location: ___________________________
Activity-Exercise Pattern
Objective
1.Cardiovascular
a. Cyanosis: No__ Yes__ Where? _______________________________
b.Pulses: Easily palpable?
Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__
Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;
Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__
c. Extremities:
i. Temperature: Cold__ Cool__ Warm__ Hot__
ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
____________________________________________________
iv. Nails: Normal__ Abnormal__ Describe: _____________________
v. Hair distribution: Normal__ Abnormal__ Describe: ____________
____________________________________________________
vi. Claudication: No__ Yes__ Describe: _______________________
____________________________________________________
d.Heart
i. Abnormal rhythm: No__ Yes__ Describe: ___________________
____________________________________________________
ii. Abnormal sounds: No__ Yes__ Describe: ___________________
____________________________________________________
2.Respiratory
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
b.Have patient cough. Any sputum? No__ Yes__ Describe: ___________
_________________________________________________________
c. Fremitus: No__ Yes__
d.Any chest excursion? No__ Yes__ Equal__ Unequal__
e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
____________________________________________________
3.Musculoskeletal
a. Range of motion: Normal__ Limited__ Describe: __________________
21 of 28
b.Gait: Normal__ Abnormal__ Describe: __________________________
c. Balance: Normal__ Abnormal__ Describe: ______________________
d.Muscle mass/strength: Normal__ Increased__ Decreased__
Describe: ________________________________________________
e. Hand grasp: Right:: Normal__ Decreased__
Left: Normal__ Decreased__
f. Toe wiggle: Right: Normal__ Decreased__
Left: Normal__ Decreased__
g.Postural: Normal__ Kyphosis__ Lordosis__
h.Deformities: No__ Yes__ Describe: ____________________________
i. Missing limbs: No__ Yes__ Where? ____________________________
j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
_________________________________________________________
k.Tremors: No__ Yes__ Describe: ______________________________
_________________________________________________________
4.Spinal cord injury: No__ Yes__ Level: ____________________________
5.Paralysis present: No__ Yes__ Where? ___________________________
6.Developmental Assessment: Normal__ Abnormal__ Describe: _________
___________________________________________________________
Sleep Rest Pattern
Subjective
1.Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ Feel rested? Yes__ No__
Describe: ________________________
2.Any problems:
a. Difficulty going to sleep? No__ Yes__
b.Awakening during night? No__ Yes__
c. Early awakening? No__ Yes__
d.Insomnia? No__ Yes__ Describe: _____________________________
3.Methods used to promote sleep: Medication: No__ Yes__ Name: _______
Warm fluids: No__ Yes__ What? __________________; Relaxation techniques: No__ Yes__ Describe:
_______________________________
Cognitive-Perceptual Pattern
Objective
1.Any overt signs of pain? No__ Yes__ Describe: _____________________
Subjective
1.Pain
a. Location (have patient point to area) : __________________________
b.Intensity (have patient rank on scale of 0 to 10): __________________
c. Radiation: No__ Yes__ To where? _____________________________
d.Timing (how often: related to any specific events): ________________
_________________________________________________________
e. Duration: _________________________________________________
f. What done relieve at home? __________________________________
22 of 28
g.When did pain begin? _______________________________________
Self-Perception and Self-Concept Pattern
Objective
1.During this assessment, does patient appear: Calm__ Anxious__ Irritable__ Withdrawn__ Restless__
2.Did any physiologic parameters change? Face reddened: No__ Yes__; Voice volume changed: No__ Yes__
Louder__ Softer__; Voice quality changed: No__ Yes__ Quavering__ Hesitation__ Other: ______________
___________________________________________________________
Role-Relationship Pattern
Objective
1.Speech Pattern
a. Is English the patient’s native language? Yes__ No__ Native language is: __________________ Interpreter
needed? No__ Yes__
b.During interview have you noted any speech problems? No__ Yes__ Describe:
________________________________________________
2.Family Interaction
a. During interview have you observed any dysfunctional family interactions? No__ Yes__ Describe:
___________________________
Sexuality-Reproductive Pattern
Subjective
Female
1.Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? No__ Yes__ Year__
2.Use of birth control measures? No__ N/A__ Yes__ Type: _____________
3.History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe:
___________________________________________________________
4.Pap smear annually: Yes__ No__ Date of last pap smear: ____________
5.Date of last mammogram: ______________________________________
6.History of sexually transmitted disease: No__ Yes__ Describe: _________
___________________________________________________________
Male
1.History of prostate problems? No__ Yes__ Describe: ________________
2.History of penile discharge, bleeding, lesions: No__ Yes__
Describe:
___________________________________________________
3.Date of last prostate exam: _____________________________________
4.History of sexually transmitted diseases: No__ Yes__ Describe: ________
___________________________________________________________
Coping-Stress Tolerance Pattern
Objective
1.Observe behavior: Are there any overt signs of stress (crying, wringing of hands, clenched fists, etc)?
Describe: ____________________________
Value-Belief Pattern
23 of 28
Objective
1.Observe behavior. Is the patient exhibiting any signs of alterations in mood (anger, crying, withdrawal, etc.)?
Describe: ___________________
___________________________________________________________
Subjective
1.Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__ Other:
_____________________________________________________
2.Will this admission interfere with your spiritual or religious practices? No__ Yes__ How?
________________________________________________
3.Any religious restrictions to care (diet, blood transfusions)? No__ Yes__ Describe:
___________________________________________________
4.Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to visit you? No__ Yes__ Who?
_________________________
5.Have your religious beliefs helped you to deal with problems in the past?
No__ Yes__ How?____________________________________________
24 of 28
DRAW A DIAGRAM OF CONCEPT MAP FOR OVERALL CLINICAL CARE
PLANNING AND RELATIONSHIP BETWEEN DIAGNOSES
Note: You may use different colored pen, dotted lines, etc to indicate relationships (See p.5)
25 of 28
Nursing Care Plan Form – Concept Mapping Format Can be used if Final Product Contains ALL elements Contained Below
Student Name:
Date:
Patient (initials only):
Patient Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is
indicated/therapeutic; provide
references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan ?)
1.
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
Statement #2
Outcome #2
26 of 28
Nursing Care Plan Form – Concept Mapping Format Can be used if Final Product Contains ALL elements Contained Below
Student Name:
Date:
Patient (initials only):
Patient Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is indicated/
therapeutic; provide references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan?)
1.
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
Statement #2
Outcome #2
27 of 28
Nursing Care Plan Form – Concept Mapping Format Can be used if Final Product Contains ALL elements Contained Below
Student Name:
Date:
Patient (initials only):
Patient Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five
subjective and/or objective
pieces of data that lead to the
nursing diagnosis)
Goals & Outcome
(Two statements are required
for each nursing diagnosis.
Must be Patient and/or family
focused; measurable; timespecific; and reasonable.)
Nursing Interventions
(List at least three nursing or
collaborative interventions with
rationale for each goal &
outcome.)
Rationale
(Provide reason why
intervention is indicated/
therapeutic; provide references.)
Outcome Evaluation &
Replanning
(Was goal met? How would
you revise the plan of care
according the patient’s response
to current plan?)
1.
Statement #1
1.
1.
Outcome #1
2.
2.
3.
3.
1.
1.
2.
2.
3.
3.
2.
3.
Statement #2
Outcome #2
28 of 28
DENVER SCHOOL OF NURSING
STUDENT VERIFICATION OF INFORMATION RECEIVED
By signing this form, I, ________________________________________, verify that 1) I have received the
Student’s Name Printed
DSN Clinical Packet; 2) the guidelines and information presented in the packet have been explained to me
satisfactorily; and 3) I agree to abide by the guidelines and information presented in the packet.
______________________________________________
Student Signature
__________________
Date
______________________________________________
Faculty Signature
__________________
Date
Faculty to return to the Education Administration Office.