NUR 3741 Clinical Work Sheet
Student Name: ___________________________________________________Today’s Date: _______________
Admission Date: ________________Male: _____Female: _____Age: ______ Height: ______inches. Admission Wt: _____ kgs.
Admitting Diagnosis: _________________________________________Current Diagnosis: _____________________________
History of Present Illness (HPI):______________________________________________________________________________
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Past Medical & Surgical History: _____________________________________________________________________________
Family Health History: ____________________________________________________________________________________
Allergy/ies + Reaction/s (specify):____________________________________________________________________________
Religious Preference: ______________________________________________________________________________________
Support System: __________________________________________________________________________________________
Occupation: ______________________________________________________________________________________________
Mental Health : (hx trauma, suicide risk, abuse) __________________________________________________________________
Social/ Cultural Data: ______________________________________________________________________________________
Code Status- DNR (No Code)/ FULL/ Neuro Endocrine IV #1 LOCATION SL / TLC / PICC / Port
DNR w/ exceptions Sltn:
Rate:
VS Frequency- Daily/ Qshift/ Q4/ Q2 Psych IV #2 LOCATION SL / TLC / PICC / Port
Time T P R BP O2 Pain GI(OG/NG) Sltn:
Rate:
PCA- NARCOTIC DRUG
Cont Bolus Q min
Resp Cardio
(RA/NC/Mask/Bipap/trach/vent) MEDICATIONS Due/ PRN-
Time
DIET TYPE-Regular/ Soft/ Chopped/ ____
Minced/ Pureed/ Other- GU GI ____
(Void/ Foley/ Urinal/ Inc/Ostomy) ____
Liquids- Thin/ Nectar/ Honey/ Pudding
Feeds self/ Requires Assist/ Total Assist Endocrine ____
____
(Enteral [Tube Feed]) via NG/ GT /JG/ PEG
Product:
____
TF Rate/ bolus: ____
Bolus Times: Skin Musculoskeletal ____
Flush amount: ____
Flush Times:
____
ACTIVITY- Up ad lib/ Bedrest (BR)/ ____
BR with BRP/ ROM/ Other-
ASSIST DEVICE- Cane/ Walker/ LABS NOTES/REPORT:
Wheelchair/ BSC/ Other- Na+ Cl- BUN
Glucose
K+ CO2 Cr
SAFETY- Fall/ Aspiration/ Seizure/
HOB @_____̊ / Restraints
Other- Hgb
WBC Platelets
Hct
ISOLATION -
Other Labs-
Treatments/ Wound Care
Procedures/ Diagnostic Tests Glucose/ Sliding Scale - BID/ ACHS Pt. Education/ Discharge Planning
Time Result Insulin Type Amt Given Location
units
units
Revised August 2019 DB
Medications
Name of Drug—Dosage—
Route—Frequency Classifications, Indication (Reason this patient is on this medication),
and Nursing Considerations of the drug
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Classification:
Indication (Your Pt):
Nursing Considerations (Your Pt):
Revised August 2019 DB
LAB VALUES AND INTERPRETATION
Baseline/ Current/
Lab Values Interpretation
Date Date
Normal Range How does this lab relate to the patient’s
HEMATOLOGY (may vary per hospital) diagnosis/medication?
WBC 4,000-10,000 /uL
RBC 4.5–5.5 million/ µL
HGB 12-16 g /dL
HCT 36%-52%
Platelets 140,000-400,000/µL
Neutrophils 54% - 75%
Lymphocytes 25%-40%
Monocytes 2%-8%
Eosinophils 1%-4%
PT
PTT
INR
CHEMISTRY
Sodium 135-145 mmol/L
Potassium 3.5-5.0 mEq/L
Chloride 100-108 mEq L
Magnesium 1.8-2.6 mg/dL
Phosphorus 2.7-4.5 mg/dL
CO2 23-29 mEq/L
Glucose 75 to 110 mg/dL
BUN 8-20mg mg/dL
Creatinine 0.6-1.2 mg/dL
Calcium 8.2-10.2 mg/dL
Protein 6.4-8.3 g/dL
Albumin 3.5-4.8g /dL
OTHER Range
GFR
BNP
UA
Diagnostic Tests (X-ray, Biopsy, C & S, Scans, or Other Special Procedure Reports
Test:_____________________________ Date:_____________
Conclusion:
Test:_____________________________ Date:_____________
Conclusion:
Test:_____________________________ Date:_____________
Conclusion:
Revised August 2019 DB
1
NURSING DIAGNOSIS and INTERVENTIONS
Instructions: Work up the #1 priority nursing diagnosis. Choose 2 outcomes (goals) with 3 interventions each. Remember
that GOALS should be appropriate to the nursing diagnosis and
S.M.A.R.T- Single and specific, Measurable, Attainable, Reasonable and Timed.
Write your Nursing Diagnosis in PES format in the box below:
P:
E:
S:
Planning: Client- Interventions/ Implementation/ Nursing Orders Evaluation/ Outcome
Centered Outcomes Write your rationale and cite your references. (Did interventions help
(GOALS) meet the goal? Explain.)
Interventions Rationale
1. a. a.
b. b.
c. c.
2. a. a.
b. b.
c. c.
Revised August 2019
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PATHOPHYSIOLOGY
Write a brief summary describing the pathophysiology of your patient’s primary
medical problem. Cite your source(s) in APA format
Revised August 2019
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Head to Toe Assessment
General:
Neurological:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genito-Urinary
Skin and Wounds:
IV (Peripheral, CVC, Central):
Revised August 2019
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DAR Note
You must write a nursing note each week. You may or may not put it in the patient’s chart, but you must write one
regardless. Your professor will instruct and assist you.
Write a DAR note per your professor’s instruction
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Revised August 2019
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Revised August 2019
