PN 206 – Practical Nursing: Clinical Notes
PN 206 – PRACTICAL NURSING CLINICAL NOTES: PATIENT CARE GUIDES,
LABORATORY INTERPRETATION, AND CASE-BASED LEARNING
Practical Nursing Program — Clinical Foundations Series
Page 1 of 17
, PN 206 – Practical Nursing: Clinical Notes
Section 1: Patient Care Guides
1.1 Vital Signs Monitoring and Early Warning Recognition
Purpose
To obtain accurate baseline and trend data on temperature, pulse, respirations, blood pressure,
oxygen saturation, and pain, and to recognize early signs of clinical deterioration.
Procedure
• Confirm patient identity using two identifiers before beginning.
• Allow the patient to rest quietly for 5 minutes before measuring blood pressure if
possible.
• Use an appropriately sized cuff — a cuff that is too small will falsely elevate the reading.
• Count respirations for a full 60 seconds without alerting the patient, since awareness of
being observed alters rate.
• Palpate the radial pulse for rate, rhythm, and quality; escalate to apical pulse for irregular
rhythms or in infants.
• Apply the pulse oximeter to a warm, well-perfused digit; note interference from nail
polish or poor perfusion.
Safety Considerations
A single abnormal vital sign should prompt a recheck before intervention, but a cluster of subtle
changes — a slightly faster respiratory rate, mild tachycardia, and a narrowing pulse pressure —
can precede overt decompensation by hours and should never be dismissed individually. Early
Warning Score tools (e.g., MEWS) exist to flag this pattern before a rapid response is needed.
Documentation
Record all values with the time obtained, the position of the patient, and the device used. Trend
graphing over the shift is more clinically useful than any single value in isolation.
1.2 Wound Care and Dressing Changes
Purpose
To promote a clean wound environment, support granulation and epithelialization, and prevent
secondary infection.
Procedure
• Perform hand hygiene and don clean gloves; switch to sterile technique if ordered or if
the wound is a surgical incision within the first 24–48 hours.
• Assess the wound bed color (red/yellow/black), size, depth, exudate amount and
character, and surrounding skin condition before cleansing.
Page 2 of 17
, PN 206 – Practical Nursing: Clinical Notes
• Irrigate with the ordered solution — typically normal saline — using gentle pressure;
avoid scrubbing granulation tissue.
• Pack cavity wounds loosely; overpacking impairs blood flow and delays healing.
• Select the dressing type to match exudate level: alginate for heavy drainage, hydrocolloid
for light-to-moderate drainage, foam for absorption with cushioning.
Safety Considerations
Increasing pain, foul odor, spreading erythema, or a change in exudate from serous to purulent
are signs of infection and should be reported promptly. Do not apply occlusive dressings over
wounds suspected of anaerobic infection.
Documentation
Wound measurements (length x width x depth in cm), tissue type percentages, drainage
characteristics, and the dressing applied should be charted at each change, along with the
patient's tolerance of the procedure.
1.3 Safe Medication Administration
Purpose
To deliver medications accurately and safely using a standardized verification process that
minimizes error.
Procedure — The Rights of Medication Administration
• Right patient — verify with two identifiers, never room number alone.
• Right medication — compare the medication administration record to the label at least
twice before administration.
• Right dose — recalculate weight-based and pediatric doses independently rather than
trusting a prior calculation.
• Right route — confirm the ordered route matches the form dispensed (e.g., do not crush
enteric-coated or extended-release tablets).
• Right time — administer within the facility's window, typically 30 minutes before or
after the scheduled time unless time-critical.
• Right documentation — chart immediately after administration, never before.
• Right reason and right response — understand why the medication is ordered and
reassess the patient afterward for therapeutic and adverse effects.
Safety Considerations
High-alert medications (insulin, anticoagulants, opioids, concentrated electrolytes) warrant an
independent double-check by a second licensed provider per facility policy. Look-alike/sound-
alike drug names should be verified against the full order, not recognized by shape or first
syllable.
Documentation
Page 3 of 17
PN 206 – PRACTICAL NURSING CLINICAL NOTES: PATIENT CARE GUIDES,
LABORATORY INTERPRETATION, AND CASE-BASED LEARNING
Practical Nursing Program — Clinical Foundations Series
Page 1 of 17
, PN 206 – Practical Nursing: Clinical Notes
Section 1: Patient Care Guides
1.1 Vital Signs Monitoring and Early Warning Recognition
Purpose
To obtain accurate baseline and trend data on temperature, pulse, respirations, blood pressure,
oxygen saturation, and pain, and to recognize early signs of clinical deterioration.
Procedure
• Confirm patient identity using two identifiers before beginning.
• Allow the patient to rest quietly for 5 minutes before measuring blood pressure if
possible.
• Use an appropriately sized cuff — a cuff that is too small will falsely elevate the reading.
• Count respirations for a full 60 seconds without alerting the patient, since awareness of
being observed alters rate.
• Palpate the radial pulse for rate, rhythm, and quality; escalate to apical pulse for irregular
rhythms or in infants.
• Apply the pulse oximeter to a warm, well-perfused digit; note interference from nail
polish or poor perfusion.
Safety Considerations
A single abnormal vital sign should prompt a recheck before intervention, but a cluster of subtle
changes — a slightly faster respiratory rate, mild tachycardia, and a narrowing pulse pressure —
can precede overt decompensation by hours and should never be dismissed individually. Early
Warning Score tools (e.g., MEWS) exist to flag this pattern before a rapid response is needed.
Documentation
Record all values with the time obtained, the position of the patient, and the device used. Trend
graphing over the shift is more clinically useful than any single value in isolation.
1.2 Wound Care and Dressing Changes
Purpose
To promote a clean wound environment, support granulation and epithelialization, and prevent
secondary infection.
Procedure
• Perform hand hygiene and don clean gloves; switch to sterile technique if ordered or if
the wound is a surgical incision within the first 24–48 hours.
• Assess the wound bed color (red/yellow/black), size, depth, exudate amount and
character, and surrounding skin condition before cleansing.
Page 2 of 17
, PN 206 – Practical Nursing: Clinical Notes
• Irrigate with the ordered solution — typically normal saline — using gentle pressure;
avoid scrubbing granulation tissue.
• Pack cavity wounds loosely; overpacking impairs blood flow and delays healing.
• Select the dressing type to match exudate level: alginate for heavy drainage, hydrocolloid
for light-to-moderate drainage, foam for absorption with cushioning.
Safety Considerations
Increasing pain, foul odor, spreading erythema, or a change in exudate from serous to purulent
are signs of infection and should be reported promptly. Do not apply occlusive dressings over
wounds suspected of anaerobic infection.
Documentation
Wound measurements (length x width x depth in cm), tissue type percentages, drainage
characteristics, and the dressing applied should be charted at each change, along with the
patient's tolerance of the procedure.
1.3 Safe Medication Administration
Purpose
To deliver medications accurately and safely using a standardized verification process that
minimizes error.
Procedure — The Rights of Medication Administration
• Right patient — verify with two identifiers, never room number alone.
• Right medication — compare the medication administration record to the label at least
twice before administration.
• Right dose — recalculate weight-based and pediatric doses independently rather than
trusting a prior calculation.
• Right route — confirm the ordered route matches the form dispensed (e.g., do not crush
enteric-coated or extended-release tablets).
• Right time — administer within the facility's window, typically 30 minutes before or
after the scheduled time unless time-critical.
• Right documentation — chart immediately after administration, never before.
• Right reason and right response — understand why the medication is ordered and
reassess the patient afterward for therapeutic and adverse effects.
Safety Considerations
High-alert medications (insulin, anticoagulants, opioids, concentrated electrolytes) warrant an
independent double-check by a second licensed provider per facility policy. Look-alike/sound-
alike drug names should be verified against the full order, not recognized by shape or first
syllable.
Documentation
Page 3 of 17
