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Clinical Assignment Packet for
Foundations of Nursing
Contents:
Clinical Limitations
Required Assignment
Physical Assessment Form
Medication Preparation Log
Nursing Care Plan Guidelines and Instructions
Scoring Rubric for Clinical Nursing Care Plans
Nursing Care Plan Forms
**Please note that nursing care plan packets are available as a separate document on the LRC
website**
Revised 03.25.13
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Revised 03.25.13
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Limitations to Clinical Experience
During this clinical rotation, students may, with instructor and/or primary nurse’s consent and
supervision, assume responsibility for all the nursing activities within the nurse’s role. The
following are exceptions to this rule.
Students may not do the following:
1. Witness any consent forms or advance directive forms.
2. Administer any IV (intravenous) push medications.
3. Perform any task that requires certification or advanced instruction (i.e., arterial blood gas
(ABG) puncture, chemotherapy, removal of central venous catheters,
interpretation/monitoring of EKGs, glucose monitoring – unless pre-approved by the nurse
manager).
4. Take physician orders either verbally or by phone.
5. Transcribe chart orders.
6. Initiate invasive monitoring
7. Regulate epidural analgesia.
8. Remove epidural catheters.
9. Remove surgically inserted drains and/or tubes (e.g., Jackson-Pratt drains, Hemovac drains)
without direct supervision by a Registered Nurse.
10. Solely monitor patient during and following conscious sedation.
11. Witness wasting or the sign out of controlled medications in Accudose, Pyxis, or Meditrol
medication delivery systems.
12. Perform end of shift controlled medication count (if applicable).
13. Have controlled drug 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. Perform any task during a code situation, except those skills learned in BLS.
17. Interventions that the facility restricts the student from performing.
18. Any skill/procedure that has not been covered in a nursing lab.
19. Medication administration should not occur in NRS 105 Foundations of Nursing.
20. Any task outside 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.
Required Assignment
For each clinical rotation, students must complete one (1) entire clinical packet to be turned into
the didactic instructor for grading.
Revised 03.25.13
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Physical Assessment Form
Patient Age: __________
Diagnosis: ___________________________________________________
Medications: See MPL
Vital Signs:
T ________ P ________ R ________ BP ________
Pain scale: ________ Location: _____________________ Type: _________________________
Diet:
Type: _______________________________
Restrictions: _________________________
Activity/MSK
Activity order: ________________________ Ability to walk (Gait): ______________________
Assistive devices: _____________________ ROM/Strength: ____________________________
Neuro:
LOC & Orientation: ______________________________ Pupils react: ___________________
Movement of extremities/weakness: ________________________________________________
Respiratory:
Lung sounds: ___________________________________ O2 delivery system: _____________
Labored/Unlabored ______________________________ Pulse Ox ______________________
CV:
Apical rate & rhythm: ________________ Peripheral pulses: ___________________________
Cap refill: ______________________
Edema: ___________________________________
GI:
Bowel sounds: _________________ Abdomen: ___________ Last BM ________ □ Incontinent
Mucous membranes: __________________
GU:
□ Voiding
□ Incontinent
□ Urinary catheter
Integument:
Color _____________ Temp _____________ Turgor _____________ Intact: Y N (if no, explain)
_____________________________________________________________________________________
Other Abnormal Findings: _____________________________________________________________
_____________________________________________________________________________________
Revised 03.25.13
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Medication Preparation Log (MPL)
Student Name: ______________________________________
Clinical Rotation Date: __________________________
Patient Identifier:
Diagnosis:
Code Status:
Relevant Medical/Surgical History:
Allergies:
Drug
(Generic/Trade)
Pt. Dose/
Normal Range
Route
Frequency
Classification
Reason pt.
receiving RX
Top 4 Side Effects
Nrsg Implications/
MUST KNOW
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Drug
(Generic/Trade)
Pt. Dose/
Normal Range
Route
Frequency
Classification
Reason pt.
receiving RX
Top 4 Side Effects
Nrsg Implications/
MUST KNOW
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NURSING CARE PLAN GUIDELINES AND INSTRUCTIONS
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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.
At least three 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 address psycho-social-cultural aspect. The data form can be found later in this
packet.
Each nursing diagnosis needs to be on a separate “Nursing Care Plan Form.” These forms can be
found later in this packet.
Please make copies of the patient data profile and nursing care plan forms and/or keep the electronic
file that has been sent to you.
Assessment
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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.
The nursing diagnosis statement is written using the PES (problem, etiology, signs/symptoms)
format:
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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
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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)
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.
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Interventions with Rationale
General guidelines:
 There should be at least three 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) Nurse will 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) Nurse will 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).
3) Nurse will consult with physical therapist for strength training and development of a mobility plan.
Rationale: Techniques such as gait training, strength training, and exercise to improve balance and
coordination can be very helpful for rehab patients (Tempin, Tempkin, & Goodman, pg. 27).
Goal/Outcome #2 interventions w/ rationale:
1) Nurse will 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 (Potter & Perry, p. 5).
2) Nurse will 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).
3) Nurse will instruct patient on proper use of assistive devices. Rationale: Patient may fall or injure self if not
using assistive device correctly (Potter & Perry, p. 6).
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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.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for individualizing
client care across the lifespan (8th Edition). Philadelphia: F. A. Davis.
Potter, P. A. & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). Philadelphia: Elsevier.
Top Achievement. Creating S.M.A.R.T. goals. Retrieved December 15, 2010 from
http://www.topachievement.com/smart.html
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Sample Nursing Care Plan
Student Name: Sally Jones
Patient Identifier: 123
Date: 3/17/08
Patient Medical Diagnosis:
Stroke
Nursing Diagnosis (use PES format): Impaired physical 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 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(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. Nurse will educate pt about
importance of ROM exercises.
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. Nurse will assist pt w/ ROM
exercises while teaching him how to
perform ROM exercises.
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).
3. Nurse will consult with physical
therapist for strength training and
development of a mobility plan.
3. Techniques such as gait training,
strength training, and exercise to
improve balance and coordination
can be very helpful for rehabilitation
patients (Tempin, Tempkin, &
Goodman, 1997)
1. Nurse will 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. Nurse will clear walkway of
hazards.
2. Pt is at risk for falls so clearing
hazards will provide a safe path to
ambulate (Potter & Perry, p. 3).
3. Nurse will instruct pt. in proper
use of assistive devices.
3. Patient may fall or injure self if not
using assistive device correctly
(Potter & Perry, p. 6).
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.
Outcome #2: Patient exceeded
goal: he walked 4 times. Will modify
plan to increase distance (to nurses’
station).
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Scoring Rubric for Clinical Nursing Care Plans
NRS 105 – Foundations of Nursing Arts and Skills
Student Name:
Grade Awarded for Assignment:
Listed below are the criteria that will be used to grade your assignment. The criteria presented
below represent the minimum expectations for that given element of your assignment. It is
expected that students will strive for more than merely the minimum score in scholarly college
work submissions.
4 = Addressed all aspects clearly, succinctly and at a scholarly
level demonstrating clear critical thinking and critical
application
3 = Addressed all aspects clearly and succinctly
2 = Addressed most of the aspects clearly but did not address
all of what was requested and/or was not succinct
1 = Addressed only a few of the aspects, was not clear and/or
succinct
0 = Did not address the aspects that were requested or
provided information that was not relative to what was
requested
Criteria
Physical Assessment Form
 Complete and accurate
Medication Preparation
 Log complete and accurate
Patient Information
 Patient initials only on care plan
 Information relevant to nursing diagnosis and
interventions is included (e.g., G/P, diabetic, support
system, etc.)
Assessment Data
 Includes objective and subjective information
 Assessment findings support chosen nursing diagnoses
 Is relevant to chosen diagnoses (e.g., infant’s EGA, wt,
temp, and environ. for diagnosis of temp imbalance)
4
Excellent
3
Very
Good
2
Good
1
Fair
0
Not
Acceptable
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Nursing Diagnosis Statements
 NANDA approved diagnoses are used
 Written in proper format (PES)
 Relevant to assigned patient
 Is supported by assessment data (i.e.,“Related to”
information is supportive of diagnosis)
 Listed from highest to lowest priority and actually
problems are listed before “risk for” problems
Plan: Goal Statements (2 goals for each diagnosis)
 Statements are patient-centered, individualized (Pt.
will)
 Are Specific, Measurable, Attainable, Realistic, Timespecific
Nursing Interventions (3 interventions for each goal)
 Are stated as instructions to provider (RN will)
 Are specific (what, when, how often, how much)
 Are related to goals
 Are prioritized, reasonable, and achievable
Rationales and References
 A rationale is present for each intervention
 Each rationale is cited (author, pg)
Evaluation and Revision of Plan
 Evaluation statements (one per goal) state whether
goal was met/ partially met/ not met
 Evaluations directly reflect goal statements
 Revision or continuation of plan is included
General
 Care plan is readable, makes sense, is practical and
realistic
 Is written in correct format
Uses Current Sources:
 A complete reference page is included for all citations
(this allows the reader to find the citation)
 Evidence from literature used to support interventions
has been published within the last five years.
Score: _____ (Maximum Score= 44 points)
Comments:
Point Conversion Table: 11 Graded Criteria (44 Maximum Points)
44
43
42
41
40
39
38
37
36
35
34
100%
97.7%
95.4%
93.1%
90.9%
88.6%
86.3%
84.0%
81.8%
79.5%
77.2%
Pass
Pass
Pass
Pass
Pass
Pass
Pass
Pass
Pass
Pass
Fail
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Nursing Care Plan Form
Student Name:
Patient Identifier:
Date:
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.
4.
5.
Statement #2
Outcome #2
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Nursing Care Plan Form
Student Name:
Patient Identifier:
Date:
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.
4.
5.
Statement #2
Outcome #2
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Nursing Care Plan Form
Student Name:
Patient Identifier:
Date:
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.
4.
5.
Statement #2
Outcome #2