Name: _________________________________
Clinical Preparation Sheet
Quincy College
School of Allied Health
PNU- 145 and 146
Client Profile
Initials:_______ Sex: M___ F___ Age:_____Race: ________
Room #:______ Date of Admission:_____________
Advanced Care Directive: Y____ N____
Do Not Resuscitate: Y____ N____ Other:______________________
Religion: ________________ Primary Language:___________________
Allergies: Foods:__________________ Drugs:_____________________
Admitting Medical Diagnosis:
(Define One):
Past Medical History:
(List)
Nursing Assessment
System Assessment Findings_________
Cardiac: Vital Signs:
Temp: PO______ PR______ AX______ TM______
Pulse: Radial_________ Apical__________
Resp Rate: ________
BP ______/______ (left-right)
History of Chest Pain: Y____ N____
________________________________________________________________________
Respiratory: Rate, rhythm:_______________________
Oximetry:______% Room Air/Oxygen
SOB: Y____ N____
Cyanosis: Y____ N____
Lung Sounds:______________________________ ________________________________________________________________________
Peripheral Vascular: CSM:____________________________________
Edema:___________________________________
Pulses-Popliteal:__________ Pedal:____________
Calf Tenderness:_______________
G.I: Diet:________________________
PO Fluid intake: _____________________ (in MLs)
Tube Feeding: Y____ N____
Type of Tube: ____________
Type & amount of feeding:_______________________
Dentures: Upper/Lower/Both
Swallowing reflex: Present/Absent
Last BM:_________ mo/day/year
Bowel Sounds:___________________________
Ostomy: Yes____ No____
Weight:_______________ Date ____________
_______________________________________________________________
G.U.: O:______
Continent/Incontinent
Urine quality:__________________
Urostomy: Y:____ N:____
________________________________________________________________________
Integumentary: Skin quality:____________________________
Wound(s):______________________________________
Description:___________________________________
Location:_____________________________________
Size:_________________________________________
Exudate/drainage:______________________________
Dressing(s):___________________________________
____________________________________
________________________________________________________________________
Musculoskeletal: Activity level:____________________________
ADLs: Self/Partial/Complete Care
Gait:___________________________________
Balance: ________________________________
Strength:________________________________
Weight Bearing:__________________________
Pain:___________________________________
Joint Mobility:___________________________
Assistive Devices: ________________________
Neurologic/Sensory: Orientation:______________________________________
Sensory impairment:_____________________________
Hearing aid(s):______________________
Glasses:____________________________
Neurologic signs:_____________________________
Seizures: Y____N____
Behavior:____________ Memory:__________
Cognition:____________
Pain Rating:_____________________________
________________________________________________________________________
Biopsychosocial – Identify biopsychosocial factors influencing health care for this client:
Family __________ Culture _________ Emotional _________
Spiritual/ Religion __________ Language _____________ Racial ____________
Identify client’s self care requisites:
Identify Interdisciplinary therapy:
Developmental stage – State Erickson’s Stage of development for this age group. Identify the positive and negative aspects. Is the client in the positive or negative area and give rationale.
MEDICATIONS: List medication, classification & purpose as it relates to client’s medical diagnosis.
Drug Dose Route Schedule Classification Purpose
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TREATMENTS: (Dressings, etc.)
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LABS:
Client Value Normal Range If abnormal, give reason
WBC__________ ( ) _______________________
Hgb___________ ( ) _______________________
Hct____________ ( ) _______________________
Na____________ ( ) _______________________
K_____________ ( ) _______________________
Cl_____________ ( ) _______________________
BUN___________ ( ) _______________________
Creatinine_______ ( ) ________________________
Glucose_________ ( ) _______________________
Other___________ ( ) ________________________
________________________________________________________________________
Nursing Care Plan
Select one appropriate NANDA nursing diagnoses based on your client’s Problems.
Provide an Etiology supporting the diagnosis and give evidence by documenting Symptoms the client demonstrates.
Choose (1) short term goal: Goals should utilize objective measurable terms. Give the goal a time frame in which the goal will be achieved.
Choose (3) nursing interventions you will incorporate in your client’s plan of care to achieve the goal.
Provide evaluation of each intervention stating to what degree the clients condition improved, worsened, or remained unchanged.
Diagnosis Short term goal Interventions (3) Evaluation ____
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E
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Note: Etiology CAN NOT be a medical diagnosis
Nursing Progress Note: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________,SPN
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Identify skills performed today & student learning needs:
Student Signature____________________________________________ Date:___________
Submit this sheet to your clinical instructor EACH clinical day at the start of post conference.
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