SHELTON STATE COMMUNITY COLLEGE

NURSING PROGRAMS

CLINICAL PHYSICAL ASSESSMENT GUIDE

Situation: Reason for admission:
Age:

Background:
Allergies:
Comorbidities:

Last Hospitalization:

Assessment:
General Survey

Cardiovascular
0800: B/P _________HR_________ Temp_________
1200: B/P _________HR_________ Temp_________
Heart Sounds
Regular/Irregular
Telemetry Y N
Pulses (0, +1, +2, +3, +4) / Location
________ ________ ________ ________
Capillary Refill
Carotid Bruits
Comments:

Awake, Alert, Oriented X4 Y N (if no make note under comments)

Physical Appearance/hygiene

IV Site: Location: ___________ Size:________Date:_____

Type: _______________

Communication barriers Y N _________________

Body Structure/Movement:

Site appearance:_______________
IV Fluids:_________________________________

Is behavior / affect appropriate Y N

Is the dress appropriate Y N
Is speech clear and appropriate Y N
Is facial expression appropriate Y N
Comments:

GI/ Nutritional
Chewing/Swallowing/feeding difficulties Y N
Type of Diet

Chief complaint:
Complaints of Pain: Acute/ chronic
Scale:
Precipitating factors
Quality
Relief measures
Region (location)
Severity
Timing
U effect of pain on patient
Last medication? ___________ Time ___________

Neuro/sensory:

Pupils (PERRLA) Y N Size______ Reaction __________

Vision
Hearing
Comments:

% Eaten B________ L________

Intake Last 24 hrs.______________
Mucous Membranes
Ht:
Wt:
Weight change __________
Last Bowel Movement __________
Bowel Continence Y N
Bowel Sounds

Comments:
Abdomen
Soft/Firm
Inspect Umbilicus
Tender/Non-tender
Comments:

Concave/Flat/Round/Obese
Distended/Non-distended

Genitourinary
Urine
color________ Consistency_______ Odor ______
Pulmonary
Frequency
YN
Urgency Y N Continence Y N
RR_____ Pattern______ Equal Y N Effort: Non-labored/Labored
Catheter
Y
N
# of days _____
Breath Sounds Anterior/ Posterior
Output
last 24 hrs. __________
Clear
Location:
Male:
Patient
Teaching
for
Testicular
Exam (optional)
Abnormal Location:
Comments:
O2 Use
Type
O2 Sat
Sputum
Comments:

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Integumentary
Color________

Lesions_________

Masses__________

Temp__________ Turgor_____________
Edema: pitting/non-pitting (0,+1, +2, +3, +4) Location________
*Braden Assessment Scale Score:
*Surgical Incision Locations (s)::

Coordinating care/Discharge Planning

Hospital day _________
Expected discharge day __________
Discharge location ___________
Is assistance needed? Y N Equipment need? Y N
Referral:
PT ______ OT______ Speech therapy _______
Chapla in ________Wound care _______ Home Care _______
Is case management seeing ______________

Comments: (Note Scars, etc.)

Plans _____________________
Breast (optional)
Color, lesions, masses
Nipple
Lymph nodes
Patient Teaching
Last mammogram
Comments
Extremities Musculoskeletal
Symmetry
Mobility/Activity Status
Equipment: cane, walker, etc.
Weakness Y N
Comments:
Restraints Y: Locations________________ N
Ability to perform ADLs
Morse) Fall Risk Assessment Score:
Educational Assessment:
Learning style: Visual/ Auditory / Physical
Highest educational level:
Diagnosis Y N
Medication Y N
Diet Y N
Pain Y N
Treatments Y N
Smoking cessation Y N
Advanced Directive Y N
Activity/ambulation Y N
Cough/Deep breathing/triflo Y N
DVT prevention Y N

Assessment Priorities
Problems or Risk for
Breathing Y N
Infection Y N
Injury Y N
Violence Y N
DVT Y N
Fall Y N
Pressure sore Y N
Comfort Y N
Vital signs Y N
Communication Y N
LOC Y N
Other:

Recommendations: (Based on Priorities)

1.

2.

3.

Does family need education? Y N

Comments
Immunizations:

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DEMOGRAPHIC DATA

SHELTON STATE COMMUNITY COLLEGE

NURSING PROGRAMS
STUDENT NAME:_______________________________________ CLINICAL SITE: __________________________ DATE: ____________________
.

Patient Initials:
Age:
Sex: M / F Allergies:
Recent Vital Signs: B/P
/
Pulse
Respiratory Rate
Current Reason for Admission/ Medical Diagnosis :
Erikson's Stage of Psychosocial Development:
Past Medical History:
Family History:

Temperature

O2 Sat

Description of Disorder/Disease Process (please write additional information on the back of this form):

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Significant Laboratory Tests and
Indications:

ASSESSMENT

______________________________________

_______________________
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Diagnostic Tests:

Risk Factors:

__________________
__________________
__________________
__________________
__________________
__________________
__________________
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__________________
__________________
__________________
__________________

_________________
_________________
_________________
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_________________
_________________

Code Status:
Height
Weight

Collaborative Care/
Management of Client Care
(See next page)

Surgical Interventions (if applicable):

_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
______________
List Applicable Nursing Diagnoses (Prioritize
and include related to information):
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
5._____________________________________
3

6._____________________________________

Subjective Data:

Objective Data:

COLLABORATIVE CARE/
________________________
MANAGEMENT OF CLIENT CARE
Medications
________________________
(Continued from Previous Page)
(See Medication Sheet)
________________________
COMPLETED PRIOR TO
CLINICAL EXPERIENCE
________________________
________________________
________________________
________________________
__
Evaluation of Client Outcomes:
Objective Data:
________________________
_______________________
________________________ ________________________
Planned Interventions (including education needs)::
_______________________
PRIORITY
NURSING DIAGNOSIS:
________________________
________________________
_____________________________________
_______________________
________________________ ________________________
_____________________________________
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________________________ ________________________
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________________________ ________________________
GOAL
________________________ ________________________
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________________________ __________
_____________________________________
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Expected
Client Outcomes
__________
_____________________________________
_______________________
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REFERENCE (APA FORMAT)
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__________________________________
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MEDICATION INFORMATION SHEET

Student Name: ________________________________________________________________

Reference:

(APA Format Only)_______________________________

Reference:

Date:_____________________
(APA Format Only)_______________________________

Generic Name: _______________________________________

Generic Name: _______________________________________

Trade Name: _________________________________________

Trade Name: _________________________________________

Classification:________________________________________
____________________________________________________

Classification:________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

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MEDICATION INFORMATION SHEET

Student Name: ________________________________________________________________

Reference:

(APA Format Only)_______________________________

Reference:

Date:_____________________
(APA Format Only)_______________________________

Generic Name: _______________________________________

Generic Name: _______________________________________

Trade Name: _________________________________________

Trade Name: _________________________________________

Classification:________________________________________
____________________________________________________

Classification:________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________

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MEDICATION INFORMATION SHEET

Student Name: ________________________________________________________________

Reference:

(APA Format Only)_______________________________

Reference:

Date:_____________________
(APA Format Only)_______________________________

Generic Name: _______________________________________

Generic Name: _______________________________________

Trade Name: _________________________________________

Trade Name: _________________________________________

Classification:________________________________________
____________________________________________________

Classification:________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason Why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Actions and Uses:____________________________________

____________________________________________________
____________________________________________________
Contraindications and Precautions:_____________________
____________________________________________________
____________________________________________________
____________________________________________________
Adverse Reactions:___________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Route and Dosage: ___________________________________
____________________________________________________
Nursing Implications:_________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Reason Why Patient is Taking the Medication: ____________
____________________________________________________
____________________________________________________
____________________________________________________
Patient Teaching: ____________________________________
____________________________________________________
____________________________________________________
____________________________________________________

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CURRENT PATIENT MEDICATIONS (Excluding PRN Medications)

Medication Name

Medication Classification

Dosage

Route

Frequency of
Administration

Reason of Medication

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