Patient Initials:
Rm #:
Cabrillo College
Clinical Preparation Sheet - Part 1
Student:
Date(s) of Care:
Pathophysiology
On the back of this sheet or a separate paper, describe in writing or by drawing a concept map the pathophysiology of the
chief complaint and the admitting disease process. Include, if you can, how the patient's other chronic illnesses or
conditions PMH (prior medical history) contributes to or affects the primary diagnosis. Compare and contrast your patient
to the textbook description of the clinical manifestations, diagnostic procedures, medical and nursing care.
Date of admission:
Chief complaint:
Age:
Doctors:
Admitting diagnosis:
Allergies:
Diet:
Date and type of surgery:
Activity Order:
Code Status:
lab ordered for date(s) of care :
PMH / Chronic conditions:
IV type & site:
Other disciplines involved in care of client (e.g. respiratory,
physical or occupational therapy, social service, etc.)
IV solution & rate:
Other:
Significant abnormal lab values
Why are they abnormal?
How are they being corrected?
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________
5. _______________________________________________________________________________________________
6. _______________________________________________________________________________________________
Diagnostic Procedures
Purpose (if unfamiliar to you)
Patient Prep & Post Care
Results
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
Tubes, lines, drains or treatments
Purpose (if unfamiliar to you)
Nursing assessment/documentation
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________
8/23/2005
Patient Initials:
Rm #:
Student:
Date(s) of Care:
Clinical Preparation Sheet - Part 2
What teaching will my pt. require? How do I prepare for it? (What
I am going to pay special attention to:
resources are available in the hospital (videos, brochures, etc.)
Time
Management
Report ___
Notes / To Do List / Questions/
Skills to review/ Words to look up
____ - ____
Quick
assessment
Airway
Breathing
Circulation
Intake
Output
Pain
Safety
Areas I was strong in:
8/23/2005
____ - ____
____ - ____
End-of-Shift 9list
Charting
MARs
Signatures
I&Os
Goodbye to pt.
Report to RN
9Pockets
No patient ID on
papers
Resources for Prep: M/S textbook;
Skills book; Lecture notes; Medical Dictionary
Pathophys. Book; N. Dx. Book; Lab/Dx book;
Drug/Pharm Book; Internet; Hospital procedure
manual ; Other:
Post-Clinical Self-evaluation
Areas needing improvement:
Patient Initials:
Rm #:
Student:
Date(s) of Care:
Clinical Work Sheet
Neuman System
Variables
Psychological
Assessment
Date/Time
Ht/Wt
LOC
Wakefulness
Orientation
Speech
Follows commands
Pupils
Swallow
INTAKE
Type
Amt
MUSC-SKELETAL
Extremity Strength
Sensation
ROM
Activity / Gait
Developmental
Developmental stage
Maturational events
Significant life events
Transitions stressors
Role
OUTPUT
Type
Amt
CARDIO
Heart Sounds
Pulses
Edema
Capillary Refill
Jugular Vein Distention
Sociocultural
Access to healthcare
Family resources
Economic status
Family structure
Ethnic-cultural
Language
Literacy
Last BM _________
Dressings & Wound
Care
PULM
O2 amt/mode
O2Saturation
Respiratory effort
Lung Sounds
Cough/Secretions
Chest Tubes
Spiritual
Religious beliefs
Spiritual values
Hopefulness
FSBG
Physiological
Safety Issues
Restraints
Fall precautions
Nausea/vomiting
Tube feeding: type/site
Other tubes/drains
GU
Urine description
Catheter
Time
Time
Insulin
Other Treatments
GI
Abdomen
Bowel Sounds
Appetite / % eaten
(start systems review)
SKIN
Color/Temp/Turgor
Braden score/stage
Hydration
IV site
Time
Assessment
Date/Time
NEURO
Coping methods
Mood/Affect
Cognitive abilities
Attitudes
Values
Memory
Thought content
Hallucinations
Agitation
Vital Signs
Physiological
(Systems Review)
HOH
Poor vision
other
Todays lab results
BP
HR
RR
Temp
Pain
8/23/2005
