NURS 1566 Clinical Form 1: Physical Assessment Short Form

MENTAL STATUS (alert and oriented to person, place and time, speech clear
and appropriate, level of consciousness):

NEURO SIGNS (pupils equal and reactive, strength equal – IF APPLICABLE):

VITAL SIGNS: AM: T P R BP SaO2 Pain

NOON: T P R BP SaO2 Pain

OXIMETRY:

SOB:

COUGH (productive, nonproductive):

LUNG SOUNDS (clear, rales, wheezes):

HEART SOUNDS (regular, irregular, rate):

ABDOMEN (soft, distended, bowel sounds):

BOWEL FUNCTION (BM, hard, soft, diarrhea):

URINARY OUTPUT (color, amount):

FOLEY CATHETER:

SKIN (warm, dry, pink):

PULSES (palpable, bilateral, strength):

EDEMA (trace, 1+ etc.):

IV’S, SALINE LOCKS, CENTRAL LINES, DRAINS, TUBES CAN BE
INSERTED WHERE APPLICABLE:

TREATMENTS:

ACCUCHECKS:

PAIN MEDS GIVEN:

NEW ORDERS, CHANGED ORDERS, PERTINENT LAB VALUES:

PRIORITY NURSING PROBLEM:

GOALS:

INTERVENTIONS:

IMPLEMENTATION:

EVALUATION:
 Clinical Form 2: Master List of Medications
Medication Name/Route Why Ordered for this patient
 NURS 1566 Clinical Form 3: Clinical Medications Worksheets
(You will need to make additional copies of these forms)

Generic Name Trade Name Classification Dose Route Time/frequency

Peak Onset Duration Normal dosage range

Why is your patient getting this medication For IV meds, compatibility with IV drips and/or solutions

Mechanism of action and indications Nursing Implications (what to focus on)

(Why med ordered) Contraindications/warnings/interactions

Common side effects

Interactions with other patient drugs, OTC or herbal Lab value alterations caused by medicine
medicines (ask patient specifically)
Be sure to teach the patient the following about this
medication

Nursing Process- Assessment Assessment Evaluation

(Pre-administration assessment) Why would you hold or not give this Check after giving
med?
Clinical Form 4: Pathophysiology

1. Submit a one page (excluding title page and reference page) report on the
pathophysiology of the disease/diagnosis that is primarily responsible for
your client’s need for medical care. You may use your textbooks as a
reference, two references are needed.
2. The report should include what the disease/diagnosis is, what the defining
characteristics are, as well, as common treatment modalities.
3. Describe how the disease/diagnosis presents itself in your client (i.e., how
do you know she’s got COPD?)
4. The report is to be typed in APA format.
Clinical Form 5: The Clinical Journal and Documentation of Self Care

Each student is required to keep a weekly journal of clinical experiences. Journals must
be turned in with the clinical packet every Friday by 9:30 am. Daily goals should be
established and evaluated by the end of the week. Journal entries should reflect critical
thinking and integration of course content.

What to write in journals:

1. Identify a goal(s) for each day.

2. Were your goals met? Explain how or why not.

3. What did you feel you didn’t know enough about with respect to your patient and

the care you provided (be specific)?

4. Do you feel that your nursing care helped your patient? Provide rational and

evidence or assessment data supporting your conclusion.

5. How did the patient condition compare with the textbook description of the

disorder?

6. What did you apply from lecture and readings this week?

7. Identify your learning needs for the next clinical week.