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ate: ________ Student Name: _______________________ Clinical Site:____________________________________
Clinical Site Instructor:___________________________________ __________________________________________
Room #_405_________Client Initials: ____SR___ ____Client age: ____52 years_______  Gender: ___Male_______
Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________
Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk)
Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________
Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________
Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________
Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________
LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8
Date  Test Normal Value Client Value Significance 
7/24 Sodium____135-145_   132
7/25 Hemoglobin 14-18    9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LABS
Look at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8
Lab Test#1: __Sodium 135-145_______________Systems affects: ______________________________________________
Elevated level: _____________________________________________________________________________
Low level: _132___________________________________________________________________________
Lab Test #2: _Hemoglobin 14-18_________________Systems affects: ______________________________________________
Elevated level: _____________________________________________________________________________
Low level: 9.4_______________________________________________________________________________
Date: ____________ Client Initials: _SR_____ Student Name: ___________________________­­­­____________________
Medical Diagnosis(s): (found in paper chart)
Admitting/Primary: Motor Vehicle Accident
____________________________________   ______________________________________
Medical History (includes medical and surgical)
 
Acute post hemorrhagic anemia _____________________________________
Alcohol abuse ___________________________________  _____________
PTSD____________________________________
Adjustment disorder with other symptoms___________________________________ ____
Traumatic ischemia of muscle__________________________________ ______________________________________
__________________________________ ______________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
End of Shift Report or SBAR: QSEN: Informatics, Team-Work Collaboration SLO: 3
 
DATE
TIME
 
 
 
 
 
 
 
 
 
 
 
Date: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________
PRN Medication List (found in paper chart) QSEN: Safety, Evidence Based Practice. SLO: 2, 4
 
Medication
(Include dose, time, route, & Frequency)
Classification
Indication for use
 
OxyCODONE   (Immediate release) 5mg tablet-10mg PO
 
Ibuprofen 400mg tablet PO q6h
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication Data Sheet
Date: ____________ Client Initials: ______ Student Name: ___________________________­­­­________________________
(Scheduled medications to be given to your client during your clinical shift) QSEN: Safety, Evidence Based Practice. SLO: 2, 4
 
Drug Name, Dose, Route   & schedule
Drug Classification,   Expected action & indication for use
Side Effects/ Adverse   Reactions
(List 3-5)
Medication/Food   Interactions
(List 3-5)
Nursing Administration   Considerations & Assessments
(List 3-5)
Client education &   Evaluation of Medication Effectiveness
(List 3-5)
 
Mirtazapine 7.5mg PO at HS
 
Nicotine 21mg/24hr Patch   Transdermal
 
Gabapentin 100mg capsule PO
 
Methocarbamol 500mg   tablet-1000mg PO
 
Enoxaparin 40mg/0.4ml   injection 40mg subcutaneous
 
Melatonin 3mg tablet PO at   HS
 
 
Date: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________
Patient________________________ Room:__________ Hallway:_____________
Nurse: ____________________________ NA: _________________________
 
Temp
Oral/Tympanic
 
HR
Regular/ Irregular
 
BP
Laying/Sitting/Standing Right/left
 
Resp.
 
O2 %
Room Air/ Oxygen _____L
 
Pain
 
Location: Description:
 
Pain Intervention:
Edema:
Location:__________________ Degree:________________ pitting/non-pitting
Lung sounds:
Right_______________________  Left_________________________
Cough?_____________________ SOB?__________________________
Bowel Sounds_________________________________________
Date of Last BM______________
Trach:
Times Suctioned: Type of Trach suction: In-Line / Sterile
Vent Settings:
RR TV HA LA PEEP Mode
LMV Sensitivity Insp Time FiO2 O2  L
Keep O2 above %
Treatments Done?
Foot care Done?
PATHOPHYSIOLOGY: For each diagnosis below, provide a 3-5 sentence explanation of the pathophysiology of the problem. (**we count sentences**) QSEN: Evidence Based Practice, Informatics, Client Centered Care. SLO: 1, 2, 4
1. Primary Diagnosis: Open displaced fracture of pelvis
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
2. Diagnosis: Alcohol dependence with withdrawal
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
3. Diagnosis: Closed fracture of multiple ribs of left side
(3-5 sentences)
Treatments: (3 minimum) 
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
4. Diagnosis: Closed fracture of transverse process of lumber vertebra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
5. Diagnosis: Acute blood loss anemia 
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
6. Diagnosis: Respiratory failure
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
7. Diagnosis: Acute pain due to trauma
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
8. Diagnosis: Transection of urethra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
Student evaluation of clinical performance:
Please describe any procedures/skills you performed/ observed during the clinical experience. Also, include your assessment of how well the day went.

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