METROPOLITAN COMMUNITY COLLEGE - Faculty …faculty.mccneb.edu/DBlum3/resources/NEW RN CLinical form... · Web viewMETROPOLITAN COMMUNITY COLLEGE RN Prelab/Critical Thinking Tool

METROPOLITAN COMMUNITY COLLEGERN Prelab/Critical Thinking Tool

To be completed for EACH assigned patient.

STUDENT NAME ________________________________Clinical Date _________________________________

Client’s Initials __________ Room ________ Code Status _______________ Date of Code Status_____________

Sex __________ Age _________ Marital Status __________________ Living Situation _____________________

Occupation ________________ Spiritual Affiliation ___________________________________________________

Maslow Hierarchy____________________________________ Erikson Stage____________________________

Primary Physician ______________________________________________________________________________

Specialty Physician(s) (list Physician/Specialty) ______________________________________________________

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Chief Complaint: _______________________________________________________________________________

Primary Diagnosis: _____________________________________________________________________________

Secondary Diagnosis (if any): _____________________________________________________________________ALLERGIES : _________________________________________________________________________________Social History:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Surgical History: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why is your patient in the ICU/CCU/HVI/PINS:_____________________________________________________________________________________________

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Revised 06/04/2015 RN Med/Surg/ICU 1

Pathophysiology: of the primary medical condition that has caused the patient to be admitted or transferred to

the ICU/CCU/HVI Unit:

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Diagnostic tests (CXR, CT, 12 Lead EKG, Echo, Etc.) completed on your patient:

Name /Type of Test Date of Test Findings/Results/Impression


Laboratory Values/Diagnostic Test Results

Laboratory/Diagnostic Test

Date of Test Normal Values Client ValuesRelate this value to your

patients condition (be specific)

What is causing this result for this client?

Make additional copies


Medication Information SheetALL MEDS MUST BE LISTED HERE --List first the scheduled medications and then PRN medications

Drug Name / Classifications

Dose, Route, Frequency and scheduled times

Action Use for This Client Side Effects / Interactions

(3)

Nursing Considerations

administration concerns(3)

---------------------- ----------------------- SCHEDULED MEDICATIONS ----------------------- ----------------------.


Medication Information Sheet (cont’d)Drug Name / Classification

Dose, Route, Frequency

Action Use for This Client Side Effects / Interactions

Nursing Considerations

administration concerns

PRN MEDICATIONS ------------------------ ------------------------ ------------------------ ------------------------

Make additional copies if needed


IV MEDICATION SHEETPrimary Maintenance IV fluids currently running and rate: 1)_________________ 2) ___________________

Example: 1) Dextrose 5% and 45% Normal Saline (D51/2 NS) @ 100ml/hr 2) Normal Saline @ 10ml/hr (TKO)

Name of Medication and

dose

Amount and Type of Diluents(list how medication

needs to be reconstituted or

diluted)

Rate of administration (How fast will you give it?)

How is this IV Medication to be given to patient?(IV Push, IV drip, IV

Piggyback [Secondary])

Is this IV Medication compatible with your Primary Maintenance

IV Fluids?Y / N

(list each # from above)

What IV medications this patient is getting

that is NOT compatible with this IV Medication?

(list these IV meds in this box)

Make additional Copies if Needed


Pre-Clinical Nursing Diagnosis

□ List 3 planned priority nursing diagnosis for this patient: (Use NANDA DX______R/T____________AEB_____________)

1.__________________________________________________________________________________________________________

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2.__________________________________________________________________________________________________________

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3.__________________________________________________________________________________________________________

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Client AssessmentTo be completed on clinical day.

Clinical Date: ________ Diagnosis: _________________________ Initials______ Age_______General Information: (Circle or fill in) Diet: NPO: Enteral type: Rate:

Parental Type: Rate:Vital Signs:Temp:Pulse:BP:Respirations:SaO2:Pain: score: Location:Description:Intervention:Recheck score:Time:_______

Vital Signs:Pulse:BP:Respirations:SaO2:Pain: score: Location:Description:Intervention:Recheck score:Time:_______

Vital Signs:Temp:Pulse:BP:Respirations:SaO2:Pain: score: Location:Description:Intervention:Recheck score:Time:________

Vital Signs:Pulse:BP:Respirations:SaO2:Pain: score: Location:Description:Intervention:Recheck score:Time: _______

Additional Comments:

Activity:

ADL: Oral Care:________________ Hygiene:____________ Skin Care:___________

TreatmentsOxygen Therapy:Type:# of liters or FiO2%:

Treatments: (circle all that apply)

SCD’s Plexi pulse TEDS

Heating blanket

Cooling Blanket HOB >30

C&DB IS Level:______

Turn q 2 and PRN(note time and position)

Other ___________________Other ___________________

Ancillary Services: (yes/no)PT/OT ________________Speech ________________Dietary ________________Social Svcs _____________RT____________________Other _________________

Tubes & Drains:

Chest Tube(s) # ________________ Location(s) ___________________Drains # _______________________ Location(s) ___________________ Location(s) ___________________ Location(s) ___________________Wound Vac Setting ______________ Location(s)____________________ # of Sponges __________________Rectal Tube ____________________Urinary Catheter ________________

Nasogastric (NG) or Oral Gastric OG)(Circle type) : Continuous SuctionLow Intermittent Suction ClampedOther ______ Position: R L mid

Feeding Tube Type: (Circle type): OG Nasal (Dobhoff) J-TubeG-Tube Output Characteristics ______________________________

Ventilator Settings:Tidal Volume: __________

Mode: __________ Rate ________

PEEP ________ PS ___________

FiO2% ____________________

ET size ________ (or) Trach _______

Placement at lip ____ Right Mid Left

Bi-Pap/CPAP:Settings:FiO2:

Continuous NOC PRNCapnography End Tidal CO2 _____ _____


Blood Sugars/Interventions

IV Site Hourly urine output

Intake Time: Output Time:

8_____9_____10_____11_____12_____13_____14_____15_____16_____17_____18_____19_____20_____21_____

#1Location:_________Fluid:_______Rate:________

#2Location:__________Fluid:____________Rate:_____________#3Location:__________Fluid:___________Rate:___________

*Others list in comment section

8_____9_____10_____11_____12_____13_____14_____15_____16_____17_____18_____19_____20_____21_____

Po____IV1_____IV2_____IV3_____IV4_____IV5_____IV6_____PB______TF______Other________________

Total Intake:

Void____Foley____CT______Rectal___Drain1___Drain2___Drain3___Other_____________

TotalOutput:

Telemetry Rhythm:

Time_____: Time_____: Time_____: Time____:

Additional Comments/Telemetry Events:

Psychosocial AssessmentTime: Time: Time: Time:

Affect: Affect: Affect: Affect:

Behavior: Behavior: Behavior: Behavior:



Time: Time: Time: Time:

Neurological Assessment

Oriented to: Person Place

Time Event

Disoriented to: ___________

Pupil Size: R 1 2 3 4 5

L 1 2 3 4 5

Response to Light:

R Sluggish Brisk Fixed

L Sluggish Brisk Fixed

Glascow Coma Scale:______

RASS Score:________




Time Event



L 1 2 3 4 5

Response to Light:




RASS Score:________




Time Event



L 1 2 3 4 5

Response to Light:




RASS Score:________




Time Event



L 1 2 3 4 5

Response to Light:




RASS Score:________


Musculoskeletal Assessment

History of Falls: Yes No

When was last:

ROM: Active Passive

Strength: Strong Weak UTA

Hand Grasps:

L: Strong Weak None

R: Strong Weak None

LegMovement:

L: Strong Weak None

R: Strong Weak None

Fall Risk Score: _______



ROM: Active Passive


Hand Grasps:

L: Strong Weak None

R: Strong Weak None

LegMovement:

L: Strong Weak None

R: Strong Weak None



ROM: Active Passive


Hand Grasps:

L: Strong Weak None

R: Strong Weak None

LegMovement:

L: Strong Weak None

R: Strong Weak None



ROM: Active Passive


Hand Grasps:

L: Strong Weak None

R: Strong Weak None

LegMovement:

L: Strong Weak None

R: Strong Weak None



Cardiac Assessment

Rhythm: Regular Irregular

Murmur: Yes No

If yes Where Heard:______

Bruit: Yes No

Dialysis bruit/thrill: Yes No

Capillary Refill:LUE: <2 sec <3 sec >3 secRUE: <2 sec <3 sec >3 secLLE: <2 sec <3 sec >3 secRLE: <2 sec <3 sec >3 sec

Radial Pulse:L: Strong Weak Dopple Absent R: Strong Weak Dopple Absent

Pedal Pulse:left: Strong Weak Dopple Absent right: Strong Weak Dopple Absent

Edema: Present Absent WeepingLUE: 1+ 2+ 3+ 4+ Pit Non-PitRUE: 1+ 2+ 3+ 4+ Pit Non-PitLLE: 1+ 2+ 3+ 4+ Pit Non-PitRLE: 1+ 2+ 3+ 4+ Pit Non-Pit

AdditionalComment:

Cardiac Assessment

Rhythm:Regular Irregular

Murmur: Yes No


Bruit: Yes No




Pedal Pulse:L: Strong Weak Doppler Absent R: Strong Weak Doppler Absent


AdditionalComment

Cardiac Assessment

Rhythm:Regular Irregular

Murmur: Yes No


Bruit: Yes No


Capillary Refill:LUE: <2 sec <3 sec >3 secRUE: <2 sec <3 sec >3secLLE: <2 sec <3 sec >3 secRLE: <2 sec <3 sec >3 sec


Pedal Pulse:L: Strong Weak Doppler Absent R: Strong Weak Doppler Absent


AdditionalComment:

Cardiac Assessment

Rhythm: Regular Irregular

Murmur: Yes No


Bruit: Yes No




Pedal Pulse:L: Strong Weak Dopple AbsentR: Strong Weak Dopple Absent

Edema: Present Absent WeepingLUE: 1+ 2 + 3+ 4+ Pit Non-PitRUE: 1+ 2+ 3+ 4+ Pit Non-PitLLE: 1+ 2+ 3+ 4+ Pit Non-PitRLE: 1+ 2+ 3+ 4+ Pit Non-Pit

AdditionalComment

Respiratory Assessment

Rhythm: Regular IrregularEffort: Labored Unlabored SOB DOE Rate: Tachy Brady ApneaLung Sounds:Anterior:RUL___________________RLL____________________RML___________________LUL____________________ LLL ___________________

Posterior:RUL ___________________RLL ___________________ LUL ___________________LLL ___________________

Other: Stridor Rub

Other:__________

Additional comment:


Rhythm: Regular IrregularEffort: Labored Unlabored SOB DOE Rate: Tachy Brady ApneaLung Sounds:Anterior:RUL___________________RLL____________________RML___________________LUL____________________ LLL ___________________

Posterior:RUL ___________________RLL ___________________ LUL ___________________LLL ___________________

Other: Stridor Rub

Other:__________

Additional comment:


Rhythm: Regular IrregularEffort: Labored Unlabored SOB DOE Rate: Tachy Brady ApneaLung Sounds:Anterior:RUL___________________RLL___________________RML__________________LUL___________________ LLL___________________Posterior:RUL __________________RLL __________________ LUL___________________LLL __________________

Other: Stridor Rub

Other:__________

Additional comment:


Rhythm: Regular IrregularEffort: Labored Unlabored SOB DOE Rate: Tachy Brady ApneaLung Sounds:Anterior:RUL__________________RLL__________________RML_________________LUL__________________ LLL__________________Posterior:RUL__________________RLL__________________LUL__________________LLL__________________

Other: Stridor Rub

Other:__________

Additional comment:


Integumentary Assessment:

Color: Normal for Race Cyanotic Flushed PaleOther (describe)

Temperature: Warm Cool Skin: Dry Moist ClammyOther(describe):

Braden Skin Assessment Score: _________














Wounds Assessment 1Type:Location of Wound:Length:Width:Depth:Drainage:Dressing:

Wounds Assessment 2

Type:Location of Wound:Length:Width:Depth:Drainage:Dressing:

Wounds Assessment 3




Wounds Assessment 5




Wound Care Notes /Treatments


GastrointestinalAssessment

Bowel Sounds:RUQ: Normal Absent Hypoactive Hyperactive

RLQ: Normal Absent Hypoactive Hyperactive

LUQ: Normal Absent Hypoactive Hyperactive

LLQ: Normal Absent Hypoactive Hyperactive

BM: Date of Last: _______BM description__________

Nausea: Y N Flatus: Y N

Abdomen: Soft Firm Round

Tender Non-tender

Mode of Elimination: Bedpan BSC BR Rectal Tube Stoma Other: ________

Additional Comment:








Tender Non-tender

Additional Comment:








Tender Non-tender

Additional Comment:








Tender Non-tender

Additional Comment:

GenitoUrinary AssessmentVoiding: No difficulty Hesitancy Frequency Unable to Void

Color:____________ Appearance:__________

Bladder Scan Y N amount_____Mode of Elimination: BRP BSC Bedpan Urinal Foley IncontinentAdditional Comments:



Bladder Scan Y N amount_____











Safety/ EnvironmentSide rails: Down 1Up 2Up 3 Up 4 Up

Bed Position: Low High

Pt Position:_______

Bed Lock: Y N

Restraints: Type: __________ Location of restraints:________________

Assess and Document:

q15min (Behavioral)

q2hrs (medical)




Pt Position:_______

Bed Lock: Y N



q15min (Behavioral)

q2hrs (medical)




Pt Position:_______

Bed Lock: Y N



q15min (Behavioral)

q2hrs (medical)




Pt Position:_______

Bed Lock: Y N



q15min (Behavioral)

q2hrs (medical)


IV SITEAssessment______________________________________________________

Change in gtt status:______________________________________________________________________________________________________________________________

CVP Reading:_______Art Reading:________











Shift Report(i.e. how this client’s assessments cares would be documented on paper)

S______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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_______________________________________________________________R___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Clinical Day Priority Nursing Diagnosis

□What is this client’s first priority nursing diagnosis for this shift? Example (Nursing Dx R/T_________AEB_________).

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□What is the goal for this client with regards to this nursing diagnosis? (SMART Goal) Client will:LT goal ______________________________________________________________________________ST goal ______________________________________________________________________________

□ List 5 nursing interventions and rationales for this client in order to meet this goal.Interventions Rationale

EVALUATION OF GOAL :

□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal could be revised.)________________________________________________________________________________________

MODIFICATION:

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Clinical Day Priority Nursing Diagnosis

□What is this client’s first priority nursing diagnosis for this shift? Example (Nursing Dx R/T_________AEB_________).

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□What is the goal for this client with regards to this nursing diagnosis? (SMART Goal) Client will:LT goal ______________________________________________________________________________ST goal ______________________________________________________________________________

□ List 5 nursing interventions and rationales for this client in order to meet this goal.Interventions Rationale

EVALUATION OF GOAL :

□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal could be revised.)________________________________________________________________________________________

MODIFICATION:

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Shift Documentation

(hour by hour account of patient careNOT WHAT U DID)

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Documents

METROPOLITAN COMMUNITY COLLEGE - Faculty …faculty.mccneb.edu/DBlum3/resources/NEW RN CLinical form... · Web viewMETROPOLITAN COMMUNITY COLLEGE RN Prelab/Critical Thinking Tool