NMSU-C NURSING PROGRAM

FIRST YEAR CLINICAL WORKSHEET

Student:       Date(s) of care:       Informant:       DOB:       Sex: Date: Of Admission:       Of Assessment:      

Health Deviation/Medical diagnosis:      

Previous illnesses and /or hospitalizations /surgeries:      

Past medications:      

Current Medications :      

Chief Complaint:      

INTAKEOF AIR

Respiratory Rate:      Crackles Rhonchi Wheezes Clear Equal Bilaterally Cough Sputum (describe)      

Described location of adventitious sounds:       Respiratory pattern:       02 Sat:      

Oxygenation Therapy (Describe):       Comments:      

Heart Rate:       ( Apical/ Radial) Rhythm: Regular Irregular Friction Rub Murmur PMI (location)      

Blood Pressure:       Position/Extremity:       Temperature (route):      

Skin: Cool Warm Moist Dry General Color (Describe):      

Nail: Shape/Color       Capillary Refill: Brisk < 2 sec. Delayed > 2 sec.

Edema (location/description):       Peripheral Pulses:      

Abnormal Lab Values:      

NUTRITION/ELIMINATION

Weight:      Height:       Ideal wt. range:       Diet Ordered:       Percent of Intake:      

Intake (oral):       (IV):       Describe IV site-location:       Type of fluid:      
IV rate:      
total intake:       hours:      

Output: urine:       Drainage:       type/location       emesis:       Total:      
Bladder habits: Continent Incontinent Foley Dialysis
Urine: Color Clear Cloudy Malodorous Blood Tinged Other:      

Abdomen: Soft Firm Distended Tender Shape Other:       Bowel Sounds:      

Date of Last BM:       Color:       Consistency:       Bowel habits: Continent Incontinent Devices

Integument: Turgor:       Mucus membranes:       Signs of breakdown:       Bruises:       Incisions:      

Altered tissue /skin integrity (location and description):      

Abnormal Lab Values:      

ACTIVITY AND REST

Activity Orders:       Tolerance:      

Current Level of Activity and Response to Activity:       Activity Limited by:      

Upper extremity strength - Right 0 1+ 2+ 3+ 4+ Lovett Scale ROM:      

Upper extremity strength – Left 0 1+ 2+ 3+ 4+ Lovett Scale ROM:      

Lower extremity strength - Right 0 1+ 2+ 3+ 4+ Lovett Scale ROM:      

Lower extremity strength - Left 0 1+ 2+ 3+ 4+ Lovett Scale ROM:      

Leisure/diversional activities:       Assistive/Supportive Devices (describe):      

Present Rest/Sleep pattern:      

Present Comfort Level (circle) Comfort 1 2 3 4 5 6 7 8 9 10 Discomfort

Client description of Discomfort:      

ADLs:       Gait:       Posture:      

Treatments/Abnormal Lab Values:      

Solitude and Social Isolation

Usual Language(s) Spoken:       Cultural Beliefs/Ethnic practices pertinent to Health Care:      

Spirituality:       Sexuality:      

Self Esteem : general appearance, eye contact, body posture, and mood:      

Pts description of self esteem (quote ) :      

Role in Family:       Support system:      

Employment:       Insurance:       Finances:      

Client/Family concerns related to illness/injury /hospitalization/discharge:      

Safety

Hazards: External       Chemical       Thermal       Auditory/Visual       Infection      

Allergies /Sensitivities:      

Visual: Glasses Contacts Other:       Pupil size and Reaction: R= / L= /

Auditory/Speech Deficits and Assistive Aids:      

Orientation: Person Place Time Situation LOC: Alert Drowsy Lethargic Obtunded Comatose

Client ID Band on wrist/side rails/call bell:      

Abnormal Lab Values:      

SUPPORTIVE EDUCATIVE NEEDS

Teaching needs for client and family:      

Discharge Planning Needs:       Resources needed or available:      

Developmental (stage of growth and development) SPRING SEMESTER ONLY: Erikson:

Piaget:: Duvall:

Textbook Picture (Pathophysiology of Primary Disease Process)

Definition and Description:      

Pathophysiology:      

Clinical Manifestations:      

Diagnostics:      

Treatment (Nursing):      

Treatment (Medical):      

References:      

Nursing Process

NURSING DIAGNOSIS ONE:      

 PATIENT GOAL (1)

     

PLANNED INTERVENTION (1)      RATIONALE FOR INTERVENTION (1)     

IMPLEMENTATION:      

PLANNED INTERVENTION (2)      RATIONALE FOR INTERVENTION (2)     

IMPLEMENTATION:      

PLANNED INTERVENTION (3)      RATIONALE FOR INTERVENTION (3)     

IMPLEMENTATION:      

PATIENT GOAL (2)

     

PLANNED INTERVENTION (1)      RATIONALE FOR INTERVENTION (1)     

IMPLEMENTATION:      

PLANNED INTERVENTION (2)      RATIONALE FOR INTERVENTION (2)     

IMPLEMENTATION:      

PLANNED INTERVENTION (3)      RATIONALE FOR INTERVENTION (3)     

IMPLEMENTATION:      

NURSING DIAGNOSIS TWO:      

PATIENT GOAL (1)

      

PLANNED INTERVENTION (1)      RATIONALE FOR INTERVENTION (1)     

IMPLEMENTATION:      

PLANNED INTERVENTION (2)      RATIONALE FOR INTERVENTION (2)     

IMPLEMENTATION:      

PLANNED INTERVENTION (3)      RATIONALE FOR INTERVENTION (3)     

IMPLEMENTATION:      

PATIENT GOAL (2)

     

PLANNED INTERVENTION (1)      RATIONALE FOR INTERVENTION (1)     

IMPLEMENTATION:      

PLANNED INTERVENTION (2)      RATIONALE FOR INTERVENTION (2)     

IMPLEMENTATION:      

PLANNED INTERVENTION (3)      RATIONALE FOR INTERVENTION (3)     

IMPLEMENTATION:      

REFERENCES: