NURS 221 CLINICAL PREPARATION GUIDE
Part A DATA COLLECTION AND NURSING CARE
Client’s Initials: ____Age:___ Room______ Patient SITUATION *Tell your Patient’s Story
(when did they first get sick, how did the illness
Admitting diagnoses: progress, treatments prescribed)
Confirmed diagnoses:
Date admitted:
Surgery procedure (include date):
Allergies (include reaction)
Code Status:
CONSULTS/Interprofessional REFERRALS How is your patient DOING NOW?
Physician Dietician Response to treatment/complications
Physical Therapist Respiratory therapy
Enterostomal Therapy
Occupational Therapist
Other:
PAST HISTORY: VITAL SIGNS
Medical Frequency of VS:
Protocols (i.e. PCA, epidural).
Research day:
Surgical BP____P_____R_____T_____Sa02____Pain____
Day1:
BP____P____R_____T_____ Sa02____Pain____
Day 2:
Mental Health BP____P_____R_____T_____Sa02_____Pain____
Interpretation of VS:
PSYCHOSOCIAL/FAMILY IV THERAPY:
Solution: Rate:
Site:
1) Peripheral:
2) CVAD: CVL___PICC___TICC____Port____
CULTURAL/RELIGIOUS Dressing:
Change due:
TPN: Lipids____Amino Acids______
PCA (orders):
Epidural (orders):
NG replacement fluids:
, PERSONAL HYGIENE OBSERVATIONS/MEASUREMENTS
Self care___ Assist____Complete Care____ Vital Signs Frequency:
Skin care Pain:
Mouth Care Neuro checks:
Hearing aid: Intake and output:
Glasses: BGM:
Dentures: Braden Score:
Other:
ELIMINATION TREATMENTS
Bowel pattern/Last BM: NG tube: ___suction___drainage
Voiding pattern/Last Void: Oxygenation:
Urinary Catheter: Wound care:
Urine output: Dressings/Drainage:
Ostomy Care Drains/output:
NUTRITION PHYSICAL ASSESSMENT (Research Day)
Diet order:
TPN: CNS
Tube feeding:
CVS
MOBILITY RESP
Activity Order
Mobility devices INTEG
Turn and position
Safety Needs/TLR GI
GU
TEACHING
MSK
EENT
DISCHARGE PLANNING ADDITIONAL INFORMATION
Part A DATA COLLECTION AND NURSING CARE
Client’s Initials: ____Age:___ Room______ Patient SITUATION *Tell your Patient’s Story
(when did they first get sick, how did the illness
Admitting diagnoses: progress, treatments prescribed)
Confirmed diagnoses:
Date admitted:
Surgery procedure (include date):
Allergies (include reaction)
Code Status:
CONSULTS/Interprofessional REFERRALS How is your patient DOING NOW?
Physician Dietician Response to treatment/complications
Physical Therapist Respiratory therapy
Enterostomal Therapy
Occupational Therapist
Other:
PAST HISTORY: VITAL SIGNS
Medical Frequency of VS:
Protocols (i.e. PCA, epidural).
Research day:
Surgical BP____P_____R_____T_____Sa02____Pain____
Day1:
BP____P____R_____T_____ Sa02____Pain____
Day 2:
Mental Health BP____P_____R_____T_____Sa02_____Pain____
Interpretation of VS:
PSYCHOSOCIAL/FAMILY IV THERAPY:
Solution: Rate:
Site:
1) Peripheral:
2) CVAD: CVL___PICC___TICC____Port____
CULTURAL/RELIGIOUS Dressing:
Change due:
TPN: Lipids____Amino Acids______
PCA (orders):
Epidural (orders):
NG replacement fluids:
, PERSONAL HYGIENE OBSERVATIONS/MEASUREMENTS
Self care___ Assist____Complete Care____ Vital Signs Frequency:
Skin care Pain:
Mouth Care Neuro checks:
Hearing aid: Intake and output:
Glasses: BGM:
Dentures: Braden Score:
Other:
ELIMINATION TREATMENTS
Bowel pattern/Last BM: NG tube: ___suction___drainage
Voiding pattern/Last Void: Oxygenation:
Urinary Catheter: Wound care:
Urine output: Dressings/Drainage:
Ostomy Care Drains/output:
NUTRITION PHYSICAL ASSESSMENT (Research Day)
Diet order:
TPN: CNS
Tube feeding:
CVS
MOBILITY RESP
Activity Order
Mobility devices INTEG
Turn and position
Safety Needs/TLR GI
GU
TEACHING
MSK
EENT
DISCHARGE PLANNING ADDITIONAL INFORMATION
