Southern Maine Community College

Nursing Clinical Worksheet

Student Name:________________ Date:______________ Instructor/Unit: Lynne Proctor R6

All information must be kept HIPAA compliant

Room number:__________ Patient initials:__________ Age:________ Gender:_________

Admission date:___________ Code status:________________ Precautions:___________________

Admission Diagnosis:____________________________________________________________

Surgical Procedure:__________________________________________________________

Allergies (include reaction):

___________________________________________________________________________
________________________________________________________________________________________
____________

1.) History of admit information: The reason the patient came into the hospital and pertinent facts related to
diagnosis. BE SPECIFIC. Describe how the patient looked upon arrival to hospital, before the diagnostic
scans and the MD diagnosis.

2.) Past Medical History:

3.) Pathophysiology: Briefly describe the pathophysiology of primary diagnosis and at least TWO other
medical problems in the patient’s history. State two potential complications of each disease process.

Primary diagnosis:

Complications:
a.
b.

1)

Complications:
a.
b.

2)

Complications:
a.
b.

4.) Procedures: Surgical and other invasive procedures done during this admission. Please define and
describe rationale for surgery/procedures.

5.) Recent diagnostic tests and procedures: Include dates and results.
6.) Discharge Plan/Needs: Where will this patient go after discharge. Are there any anticipated needs for
care/services, spiritual needs, educational needs.

7.) Medications: List all medications, including IV, IM, PO, SC, and PRN. For continuous IV drips include
dosage (units/hr, mg/hr, mcg/kg/min,etc) and rate (ml/hr)

Drug Dose, Mechanism Of Action Major Side Effects/Food Reason Nursing

(trade Route, Drug Interactions For Use In Considerations
and Frequency, This
generic Safe Particular
names) Dosage Patient
& Drug Ranges
Class
Drug Dose, Mechanism Of Action Major Side Effects/Food Reason Nursing
(trade Route, Drug Interactions For Use In Considerations
and Frequency, This
generic Safe Particular
names) Dosage Patient
& Drug Ranges
Class
Drug Dose, Mechanism Of Action Major Side Effects/Food Reason Nursing
(trade Route, Drug Interactions For Use In Considerations
and Frequency, This
generic Safe Particular
names) Dosage Patient
& Drug Ranges
Class
 8. Lab Results: Note abnormal values and state why this lab value is abnormal specific to your patient.
Note trends in lab values. Add any additional labs test
**K+,Mg+,&Ca+ tied together to maintain neutral intracellular electrical charge.
Lab Study Normals Date Date Date Purpose Of Lab Reason For Abnormal
Time Time Time in THIS PARTICULAR
PATIENT
Glucose 70 -119 Check glucose production,
insulin secretion Monitor
diabetes
Sodium 136-145 Check renal function and
hydration. Balance b/t dietary
intake and renal excretion.
Potassium 3.5-5.0 **Check kidney function and
electrolyte status. Has
profound effects on heart rate
and contractility.
Chloride 98-112 Check kidney function and
electrolyte status. Along with
other electrolytes can give info
acid/base balance and
hydration
CO2 22-31 Checks venous bicarb. Can
help with acid/base
determination.
BUN 7-21mg/dl Measures nitrogen content of
blood in form of urea. Tests
kidney function
Creatinine 0.5- Final product of creatine
1.4mg/dl catabolism. Tests kidney
excretion and function
Magnesium 1.6 – 2.1 **Critical electrolyte in almost
all metabolic processes.
Calcium 8.9-10.3 **Evaluates parathyroid
function and calcium
metabolism.
Albumin 3.5-5.0 Protein that is synthesized by
liver. 60% of protein in blood is
albumen. Maintains osmotic
colloidal pressure.
Total 6.0-8.3 Protein in blood which helps
Protein determine nutritional status

WBC 4.8-10.8 Immune function cells

(leukocytes). Tests body’s
reaction to stressors, infection,
allergens
HgB 12.0-16.0 : Reflects the total number of
RBCs in the blood
Hct 37%-47% Tests percentage of total blood
volume made up of RBCs
Platelets 140K-440K Cells that form clumps to make
clots
Measurement of platelet count.
PTT 20-25 Evaluates the function of the
seconds intrinsic clotting system.
Tests anticoagulant effect of
heparin
Protime 11.5-13.1 Evaluates the adequacy of
seconds extrinsic system & common
clotting pathway.
Tests anticoagulant effect of
warfarin
INR 0.9-1.1 = Tests anticoagulant effect of
normal warfarin for which it must be
2-3 = drawn on regular basis. This
therapeutic is a standardized
normal nomenclature that is used
dose world-wide. Often drawn just
warfarin once prior to invasive
2.5-3.5 = procedures to test clotting.
therapeutic
high-dose
warfarin
CPK 55 –170 Found in cardiac muscle,
units/L skeletal muscle, and brain.
(male) Serum levels are elevated
30 –135 whenever injury occurs to
units/L these muscle or nerve cells
(females)
0% Isoenzyme specific to
CPK-MB Relative myocardial cells. Elevation
isoenzyme index (CPK- occurs after an infarction. Can
MB to total also be elevated in patients
CPK) is with shock, malignant
looked at to hyperthermia, myopathies,
avoid myocarditis, and severe
misdiagnos skeletal injury.
es
Biochemical marker for cardiac
Troponin I < 0.03ng/ml disease. Troponins are
proteins that exist in cardiac
muscle.
Natriuretic peptide thats
BNP < 100pg/ml highest level is in the cardiac
ventricular muscle. Secreted
when there is a stretch in the
atrial or ventricle muscle.
Used as an indicator for CHF.
9.) Clinical Assessment Findings: You MUST have Maine Medical Center Adult Assessment Parameters in order to
complete this assessment tool.
Vital Signs:
0800:__________________________________
1200:______________________________________
1600:______________________________________

Neurological: Level of orientation, behavior, movement, sensation quality of speech, level of

consciousness, swallowing reflex.
Pupil Size:
Right: 2mm 3mm 4mm 5mm Normal Brisk Sluggish
Left: 2mm 3mm 4mm 5mm Normal Brisk Sluggish
Droop: Left Right Drift: Left Right
Swallow: Intact Difficult__________________________________
Memory Recall: ________________________________________________________________
Speech Quality_________________________________________________________________
Visual deficits________________________________Photosensitivity?_______________________
Neglect_______________________________________________________________________
Aphasia(describe)_______________________________________________________________
Posturing:_____________________________________________________________________

Mental Status: Will include level of consciousness and level of orientation.

General: Anesthetized Awake/Alert Comatose

Oriented: To person To person and place To person, place, and time
Disoriented:_describe_________________________________________________________________
____________________

GCS:
Eye Opening: 4. Purposeful/spontaneous 3. To voice 2. To pain 1. None
Verbal: 5. Oriented 4. Disoriented 3. Inappropriate words 2. Nonverbal/sounds only 1. None
Motor:6. Obeys commands 5. Localizes pain 4. Withdrawal 3. Flexion 2. Extension 1. None

Total Score: _______

Mobility/Strength: Moves against resistance Moves above gravity

Minimal movement Immobile
Grasps: Strong Weak Equal Leg strength: L: 1 2 3 4 5
Hand strength: L: 1 2 3 4 5 R: 1 2 3 4 5 R: 1 2 3 4 5

Note_______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________
Pain: Will include patient description: type, location, duration, radiation, and intensity on appropriate
pain scale; precipitating factor, and alleviating factors.
Pre and post pain scale for every time med administered:
Time: Med: Dose: Pre: Post:
Time: Med: Dose: Pre: Post:
Time: Med: Dose: Pre: Post:
PCA/Epidural Settings:_______________
Amount used@ 0800:_______/RR______
@1000________/RR______
@1200________/RR_______
@1400_______/RR________
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________

Cardiovascular: Will include heart rate and rhythm; peripheral pulses; edema, skin temperature and
color.
AP heart rate for 60 seconds: ____________ Pulse: regular Irregular
Drugs affecting HR:_________________________________________________________________
Orthostatic changes: Yes _____ No _____
Drugs affecting B/P:__________________________________________________________________
IV fluids (rate, type, site):______________________________________________________________

Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________

Respiratory: Will include rate, regularity, depth and ease of respirations; lung sounds; cough;
amount, color, odor, and consistency of sputum or nasal drainage.
Respiratory rate: ________
Respiratory quality: Deep Shallow Unlabored Labored Symmetrical Asymmetrical
Breath sounds right:__________________________________________________________________
Breath sounds left:__________________________________________________________________
Fremitus: Normal Decreased Increased
Cough present:__________
Color, consistency, and amount of sputum:_______________________________________________
Oxygen therapy: __________________________________
Incentive spirometry use:_____freq.______
Pulmonary Medications: _____________________________
Effect: ______________________________
Pulmonary Toilet:
________________________________________________________________________
02 Sat: ______________________RA__x________# of liters:_________
Chest Tube R @: _______ cm LCS/H2O seal Drainage: ______ over: _____hrs
Chest Tube L @: _______ cm LCS/H2O seal Drainage: ______ over: _____hrs
Trach: Type________________________Size______________________________
Replacements at bedside? Green card?
Suctioned___________________________________________________________
Trach care provided___________________________________________________
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________

Gastrointestinal/Nutrition: Will include abdominal appearance; bowel sounds; palpation; diet

tolerance; presence of nausea or vomiting, pattern of bowel movements.

Bowel sounds: None Hypoactive Active Hyperactive

Abdomen: Distended Nondistended
Last stool (amount/consistency): ______________________________________
Tenderness: Yes_____ No_____
Diet: ____________________________
Glucose checks: 0700__________Carbs eaten_______Insulin given: type/units_________
1200__________Carbs eaten_______Insulin given: type/units_________

Presence of NG tube/feeding tube: Yes____ No_____

If yes, describe:_____________________________________________________________--
Ng tube to suction: settings________________ amount of gastric output:________/______/______
Q4 h replaced_____/_____/_____
Residuals checked @________ amount______

Note:______________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________

Renal/Fluid Balance/GU: Will include amount, color and odor of urine; voiding patterns or catheter
patency; bladder distention, presence of vaginal/penile discharge or irritation.
Foley_____ Condom cath______ Suprapubic_____
I&O q4h 0800:I________/O_____1200:_I_______/O________1600:I________/O________
Voids: Continent Incontinent
Urine: clear cloudy straw yellow amber bloody
Sediment: Yes_____ No_____ Last UA: ______________
Foley care:_________time:________
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
 __________________________________________________________________________________
_________

Integument: Will include integrity, hygiene, skin color, condition, temperature; turgor, condition of
mucous membranes; if stoma present: stoma color, size and shape, status of peristomal skin, presence
of stomal bleeding. Braden Scale Score.

Skin color: _________________ Skin temperature: _______________ Skin turgor:_______________

Breakdown/pressure sore:____________________________________________________________
Braden scale #: _______________
Ecchymosis: ______________________________________________________________________
Interventions: Elevated Heels Foot Cradle DUO derm Sensicare Multipodus
Pt repositioned @______/_______/_______

Note:______________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________

Functional: Will include the observation of balance, strength, functional activity, use of assistive
devices.
OOB X: _________ To chair:_______ duration:_____
Ambulated:______ #assists:_____ Stairs:__________
Assistive Devices:____________
Weight bearing status:__________________

Teds: Right Left Both

Fall risk precaution score:___________
Venodynes: Right Left Both
CPM Machine: side:_____degree of flexion:______________Duration:________________________
Cryocuff: R L
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________
Musculoskeletal: Will include joint swelling, tenderness; limitations in functional ROM; muscle
strength and tone and condition of surrounding tissue. right hip and hands and shoulder r/t
arthritis

Neurovascular: Will include color, temperature, movement, pulses, capillary refill, edema,
tenderness, presence of ulcers, and patient description of sensation of affected extremity.
Edema: Face/neck Dependent Peripheral General Pitting#__________

Pulses (0-3+): Left radial: ____ Right radial: _____ Left DP: _____ Right DP: _____
Left PT: _____ Right PT: _____
Pulses: palpable (p) via Doppler (d)
Feet warm? Left Right
Note:______________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________________________________
IV Site: Will include the observation of the insertion or exit sites of catheters (peripheral, arterial,
central venous and/or epidural) for: temperature, color and integrity of surrounding tissue; any
drainage or pain and catheter patency. VIPAS Scale assessment.
IV Lines __________________________ Date inserted: ___________ VIPAS Scale:_______
PICC location_____ Date dsg changed__________________________
Note_______________________________________________________________________________
_________________________________________________________________________________

Dressing: Will include condition of dressing, drainage on dressing; wound suction drains (if present)
for patency and drainage.

How often is dressing changed?_________________

Drainage consistency on dressing________________________ Drains:
JP drain__________ Amount of drainage:_________
Ventriculostomy: ____________________________________________________________
Note:______________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________
Incision/Wound: Will include color, temperature and tenderness of surrounding tissue; condition of
sutures, staples or steri strips; approximation of wound edges; amount, color and odor of
drainage. Incision suction drains (if present) for patency and drainage.
Drains: JP op:_______ CVAC op:________ Ventriculostomy op: _________
VAC dsg location____________settings:___________________amt of drainage_______
Size of wound__________________________________________________________
Surgical_______________________________________________________________
Pressure ulcer___________________________________________________________
Trach dsg______________________________________________________________
PEG dsg_______________________________________________________________
Traumatic wound________________________________________________________
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________

Psychosocial/ Learning: Will include knowledge of diagnosis and treatment; language, cultural,
religious, psychosocial and financial issues which impact learning; ability to comprehend; readiness to
learn; learning style; barriers to learning. Define coping mechanisms used by patient and the
effectiveness.
Note:______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________

10) Nursing Care Plan:

Preliminary plan of care, completed for first clinical day with patient. This is what you think
should be the focus based on pre-clinical preparation. Add a second diagnosis after you care for
the patient. DO NOT RESTATE THE FIRST ONE. When you turn this in it should be
complete and you can add to your hypothesis diagnosis to make it well defined. DO NOT USE
interventions that you did not do or expectations that are unrealistic.

1. Hypothesis
Nursing Diagnosis Problem:

Related to (causes):

As Evidenced by (symptoms):
Desired Outcomes (patient criteria):

Interventions:

Nursing Diagnosis Problem:

Related to (causes):

As Evidenced by (symptoms):

Desired Outcomes (patient criteria):

Interventions:
Journal:
Required weekly.
Below describe the challenges you faced this week. How did you deal with them?
What would you do different in the future?
Describe any new experiences and your reactions to them.
Use this to show me what you did today. How you helped your patient. What you did for
them!
You may also include any questions that you have for me and any issues that arose.