\GOODWIN COLLEGE Student Name:________________________Unit:______

NURSING CARE CLINICAL WORKSHEET Clinical Date:_________ Date of Admission:__________

Packet is to be completed AFTER the clinical experience.
I. PERSONAL PROFILE (PSYCHOSOCIAL): (Interview the client, review/abstract client medical
record). USE TEXTBOOK: Potter/Perry as a reference tool to provide you information regarding data collection
& the nursing process.”***” Student is required to know prior to caring for the client.
Room#: Smoking History:
*** (ppd times # years)
Patient Initials: Alcohol History:
***
Age: Drug History:
***
Race: Current Stressors In
*** Life
Gender: Hobbies/Recreational
*** Activities:
Marital Status: Insurance Coverage

Religion: Level of Education

Family Structure Primary Language:

***
Code Status, Drug/Food Allergy:
identify limitations What occurs:
*** ***
Occupation: Other:
***

II. PATIENT HISTORY/COMMORBIDITIES: (Bullet medical diagnosis(es) and surgeries the client has/had.
List dates diagnosed or surgery performed). USE TEXTBOOK: Ignatavicius as a reference tool to provide you
information regarding the definition, pathophysiology, signs/symptoms, treatments and nursing process of the
patient’s past history.
Month/Year Diagnosed Diagnosis/Surgery Patient History

III. ADMITTING DIAGNOSIS PATHOPHYSIOLOGY: (Complete the admission diagnosis abstract form, in
addition complete a diagnosis abstract form for a minimum of two (2) additional comorbidities that contribute or
impact the admitting diagnosis or other additional medical diagnosis. USE TEXTBOOK: Ignatavicius as a
reference tool to provide you information regarding the definition, pathophysiology, signs/symptoms, treatments
and nursing process of the patient’s admitting diagnosis. “***”=Student must know prior to caring for the client.”
Admitting Diagnosis:_***_______________________________________________________________________

Surgery during this hospitalization if applicable:_______________________________________Date:_______

III. #1-Admission Diagnosis Abstract Form

for:_____________________________________________________________________________________
USE TEXTBOOK: Ignatavicius page #:_____________Other Source:________________________________

In your own words how

would you define/explain this
diagnosis to your client/family
member?

Assessment:
Signs/Symptoms of diagnosis

Medical/Surgical Diagnostics:
Treatments:

Examples of Medications Classification Trade Generic

Used to Treat Disease:

.
Potential Complications:
III. #2-Comorbid or Other Diagnosis Abstract Form for:

________________________________________________________________________________________
USE TEXTBOOK: Ignatavicius page #:___________Other Source:_________________________________

In your own words how

would you define/explain this
diagnosis to your client/
family member?

Assessment:
Signs/Symptoms of diagnosis

Medical/Surgical Diagnostics:
Treatments:

Examples of Medications Classification Trade Generic

Used to Treat Disease:

.
Potential Complications:
II. #3-Comorbid or Other Diagnosis Abstract Form for:

______________________________________________________________________________________
USE TEXTBOOK: Ignatavicius page #_________Other Source:__________________________________

In your own words how

would you define/explain this
diagnosis to your client/family
member?

Assessment:
Signs/Symptoms of diagnosis

Medical/Surgical Diagnostics:
Treatments:
Required

Examples of Medications Classification Trade Generic

Used to Treat Disease:

.
Potential Complications:
IV. CURRENT/RECENT DIAGNOSTIC TESTS/STUDIES/PROCEDURES: (i.e. X-ray, ECG, bone scan,
etc.) USE TEXTBOOK: Ignatavicius, Potter/Perry as a reference tool to provide you information regarding the
reason diagnostic test, study or procedure performed and normal/abnormal results.
Test/Study/Procedure & Reason ordered for your client. Result
Date Ordered

V. CURRENT NURSING INTERVENTIONS: USE TEXTBOOK: Ignatavicius, Potter/Perry, Ackley as a

reference tool to provide you information regarding nursing interventions.
Date Intervention Reason for intervention Evaluation of Intervention (What was the
Time for any client result, provide subjective and objective data).
(Potter/Perry)
Vital Signs Time: Time:
Temp: Temp: Temp:
Pulse: Pulse: Pulse:
Respiration: Respiration: Respiration:
BP: BP BP
Pulse Ox % via Pulse Ox % via Pulse Ox % via
Pain Pain Pain
Intake/Output

IV Fluids/Rate, site Describe site as well.

Saline/Heparin Lock
NG, GT, JT
Size/Suction, Feeding
Activity Level

Range of Joint Motion

Foley Cath

Dressings

TED Hose/Kendall,
Compression Stockings
Special Mattress

Casts/Location
Traction
Pacemaker,
Remote Telemetry
Chest Tubes, Trach,
Ventilator
Restraints
Blood Glucose
(Finger Stick)
Other
Other
Attach additional sheet of paper to clinical worksheet if needed.
VI. LABORATORY TEST RESULTS: (Complete information below). USE TEXTBOOK: Pagana & Pagana
reference tool to provide you information regarding purpose of laboratory test & reasons for abnormality.
Lab Test Normal Date Date Date Purpose/Reason for Reason for Abnormality ONLY
Admit performing lab test on Link with your diagnosis(es),
Result Result Result your client. surgery or procedure performed
Glucose 70-105
BUN 10-20
Creatinine 0.5-1.1-Female
0.6-1.2 Male
Calcium 9.0-10.5
ALP 30-120
CO2 23-30
Sodium 136-145
Potassium 3.5-5.0
Chloride 98-106
Magnesium 1.3-2.1
Chloride 98-106
Phosphorous 3.0-4.5
WBC 5000-
1000/mm3
Segs 50-70
Bands <10
Lymps 20-40%
RBC 4.2-5.4 Female
4.7-6.1 Male
Hgb 12-16 Female
14-18 Male
Hct 37%-47%
Female
42%-52% Male
Platelets 150,000-
400,000
pH 7.35-7.45
PCO2 35-45
PO2 80-100
HCO3 22-26
CPK 30-135 Female
55-170 Male
Troponin <0.2
Cholesterol <160
Triglycerides 35-135 Female
40-160 Male
PT 11-12.5
PTT 20-36
INR 0.8 – 1.2
Pre-Albumin 15-36
Albumin 3.5-5
Bilirubin-T 0.3-1.0
TSH 2-10
VII. MEDICATIONS: (List all scheduled and prn medications administered 24 hours prior and during your shift. USE: www.nlm.nih.gov/medlineplus & Mosby’s Drug
Reference
REQUIRED for NUR 100, NUR 110 and NUR200 ONLY
Date Medication Drug Class / Drug Action Major Side Effects , Food, Drug Interactions Reason Ordered / Evaluate Effectiveness
Nursing Implications
Generic: Classification : Side Effects: Reason Ordered:

Trade: Food:
Action: Was Med Effective Or Not-Document with “S” and/or “0”
Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Food:
Action: Was Med Effective Or Not-Document with “S” and/or “0”
Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Food:
Action: Was Med Effective Or Not-Document with “S” and/or “0”
Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Food:
Action: Was Med Effective Or Not-Document with “S” and/or “0”
Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Date Medication Drug Class / Drug Action Side Effects , Food, Drug Interactions Reason Ordered / Evaluate Effectiveness
Nursing Implications
Generic: Classification : Side Effects: Reason Ordered:

Trade: Action: Food: Was Med Effective Or Not-Document with “S” and/or “0”

Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Action: Food: Was Med Effective Or Not-Document with “S” and/or “0”

Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Action: Food: Was Med Effective Or Not-Document with “S” and/or “0”

Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

Generic: Classification : Side Effects: Reason Ordered:

Trade: Action: Food: Was Med Effective Or Not-Document with “S” and/or “0”

Dosage: Drug:

Admin. Time: Nursing implication(s)

Route: Effective: Yes / No

VIII. SPECIFIC THERAPEUTIC COMMUNICATION SKILLS/TECHNIQUES: (What therapeutic
communication techniques do you plan to utilize or have utilized during your discussion with the client, why
did you use the specific technique-what data/information did you obtain). USE TEXTBOOK: Potter/Perry,
pages 437-440 (Implementation-Therapeutic Communication Techniques) as a reference tool to provide you
information regarding data collection & the nursing process.
REQUIRED FOR NUR 100 AND NUR 110 ONLY
Include Verbal and non-verbal communication techniques.

IX. MEDICAL COMPLICATIONS OR NURSING CARE ISSUES WHICH HAVE OCCURRED

DURING THIS ADMISSION WHICH HAVE EXTENDED THE LENGTH OF STAY.. USE
TEXTBOOK: Ignatavicius as a reference tool to provide you information regarding complications, continuing
care needs. Link with admitting diagnosis(es) and commordbidities.
X. TEACHING NEEDS -May include client, family or staff: (i.e., medications, interventions,
hospitalization/long term care/rehab, treatments, disease process, health promotion, restoration or preventive
activities, discharge planning teaching needs). What did you teach? How did you teach it?, Identify barriers to
teaching? Discuss how you implemented the teaching plan and how you evaluated achievement of the teaching
goal. USE TEXTBOOK: Ignatavicius, Potter/Perrry & Ackley as a reference tool.

Specific area(s) requiring teaching:

Barriers to learning:

Specific content taught:

Methods used to teach:

Was your teaching effective and how did you know?

XI. NUTRITION SUPPORT (ROUTE, TYPE, TOLERANCE) Discuss clinical observations, laboratory
data, diet hx, height/weight ratio, and psycho-social data. Include current diet, why on this diet, feeding
schedule, what foods to eat/avoid, intake/output). Consult ht/wt graphs in chart. If on calorie count,
supplemental feedings, or fluid restriction, then please state rationale.) USE TEXTBOOK: Ignatavicius,
Potter/Perry, Ackley, Pagano & Pagano..

Height:__________Weight:_________BMI:_________Current Diet:_________________________________

What they eating/drinking:

What they should be consuming:

What they are consuming:

XII. DEVELOPMENTAL INFORMATION: NOT REQUIRED FOR NUR 220 (Describe expected
Erickson’s stage developmental level based on age. Use your health assessment textbook or handouts to
determine expected developmental level. Identify normal development or abnormal development if present for
your client based on your own data collection. State two nursing interventions to promote appropriate activity.
Assess what stage of Erickson the client is experiencing and why did you make that assessment. Include
appropriate bulleted interventions to address any issues. USE TEXTBOOK: Potter/Perry.
XIII. Link the admitting diagnosis, patient history/commorbidities. USE TEXTBOOK: Ignatavicius
&Potter/Perrry. NOT REQUIRED FOR NUR 220
XIV. System Assessment – Clinical Day Assessment – Clinical Day -5 Bullets each System
Central Nervous System/Neurological - Alert &
oriented X3 to PPT; follows commands; speech clear;
orientation; hand grasps; pedal push; PERRLA;
level of consciousness; shoulder shrug; ability to feel
objects; sense of touch; any seizure activity, shaking,
trembling, facial droop, drooling; lethargic;
somnolence; fatigued. Mentation – Judgment, mood,
confusion, agitation, anxiety. Speech Pattern –
Coherence, lucidity, logical, mumbled, does not
communicate, aphasic.

Head/Neck - EENT Mucous membranes pink moist,

no redness or discharge, lumps/bumps, shape,
abnormal absence or presence of hair, symmetry of
shape, pain, jaundice, visual impairment, dentures
(upper/lower).
Cardiovascular - HR regular/irregular, apical pulse
rate, +/- peripheral pulses, edema, capillary refill,
abnormal sounds (including carotid), pulses
(radial/pedal), temp/color of extremities, c/o pain,
palpations.
Respiratory - Breath sounds heard & location
(adventitious sounds), O2 sats, amount & type of O2,
labored breathing (use of accessory muscles),
cough/sputum color, sputum consistency, pain,
respirations regular, unlabored, identify lung sounds
according to specific lobes.

Gastrointestinal - Abdomen soft, bowel sounds

positive in all quadrants, abdominal distention,
abnormal bowel sounds (hyperactive/hypoactive),
lumps, bumps, skin abnormalities, pain, stool guiac
+/-, date of last BM, enema administered/results.
Describe BM, formed, loose, liquid, large stool, small
amount, ostomy, incontinent, diapered, PEG or
NGT, BRP.
Genitourinary/Reproductive – Dribbling,
incontinent, frequency, burning, nocturia, UTI,
hematuria, stones, difficulty starting stream,
retention, distention, pain, catheter, stoma, dialysis &
location of dialysis catheter/stent. Female –
menstrual history, discharge, performs breast exam,
pain, sexual history prn. Male – performs testicular
exam, discharge, pain, sexual history prn.
Musculoskeletal - Balance, gait, pain, muscle mass,
MAE, muscle weakness, steady balance and gait,
passive ROM performed, OOB w/assist of 1, 2, or
special equipment
 Integumentary - Skin warm, dry, intact, turgor
elastic, red, scaly, shiny, no hair on legs/arms, color,
moisture, temperature, lesions, bumps, jaundice,
texture, cleanliness, dressing, describe any surgical
wounds, thin skin, skin tears, ecchymotic, Pressure
Ulcer: record stage, location, size, drainage

DEPENDENT ON THE FACILITY’S DOCUMENTATION POLICY/PROCEDURE

STUDENTS SHOULD WRITE A SOAP NOTE, NARRATIVE PROGRESS NOTE, PES
NOTE OR WHAT EVER TYPE OF PROGRESS NOTE THAT THE FACILITY
UTILIZES. The SOAP Note Guide below is provided for those facilities that utilize SOAP note format.
XIV: SOAP NOTE GUIDE: What at risk or actual nursing diagnosis did you address during your shift?
USE TEXTBOOK: Ignatavicius, Potter/Perrry, Ackley.
Problem:
NURSE DX Problem:

Subjective: WRITE DOWN IN PATIENT’S OWN

WORDS WHAT THEY SAID TO YOU S
What did patient, family member or significant other say or
express as a point of view.
May include:
• Any information about how the problem or its effects
are perceived by the patient or the family
• Onset: date/time, type (acute, gradual.
• Intensity, quality, location, radiation.
• Number and length of episodes.
• Precipitating factors.
• Sources of relief: position, medication, etc.
• Factors that make it worse.
• Feelings/emotional reactions to the problem
Objective: WHAT DID YOU MEASURE, OBSERVE,
DO? O
What was your actual clinical observation, physical
assessments, or laboratory findings.
Observations can include:
• Chills, sweating, facial grimaces, restlessness,
withdrawn, nervous.
Measurement can include:
• BP, T, P, R, Pain scale, I&O’s, Pulse ox
Things you did:
• Treatments performed, medications given, assistance
with basic needs/ADLs, physician notified or referral
made.

Assessment: WHAT IS YOUR NURSE DX

Your assessment is a statement that reflects what you think is A
happening. Take the subjective and objective information and
apply it. Does it still persist, continue?

Plan: WHAT WILL YOU DO AND WANT TO

COMMUNICATE TO OTHERS TO MANAGE THE P:
PROBLEM?
This may include: Continue to assess for s&s of
• Continue to assess (___________). ___________________________
• Monitor (nurse dx)
• Turn & position, cough and deep breath.
• Education plans
XV: NURSING CARE PLAN: USE TEXTBOOK: Ignatavicius, Potter/Perrry, Ackley.
Diagnosis-Nursing(NANDA):

____________________________________related to________________________________as evidenced by______________________________

Source Used:____________________________________________________________Page#:_______________

Assessment Planning Goals Interventions Evaluation

Under “Defining Characteristics” in
Ackley. Include a minimum of 10 to
+/- defining characteristics,
subjective/objective findings that
support your selected nursing
diagnosis.
Under “Client Outcomes” in Ackley.
Keep it simple.
STG: What can be done on your shift
that you will be able to evaluate today
during your shift.
LTG: What should the patient
achieve by discharge from hospital
or >30 days in long term care.
Under “Nurse Interventions and
Rationales” in Ackley.
Document both the intervention &
rationale.
Did your patient achieve the goals
listed in the “Planning Goals”
section? If not, assess why not &
document how you would revise
your planning goal?

Subjective Data:

Objective Data:
XVI: Clinical Journal Name:_________________________________
Clinical Date:___________________________

My personal objectives for the week:

Perceptions of your own strengths and weaknesses:

How was your clinical day?

What did you learn today?

What would’ve you liked to change?

How could’ve I (instructor) made it better for you?

Clinical Worksheet Weekly Evaluation Name:______________________________
(To be completed by Clinical Faculty Member) Clinical Date:________________________

Section Section Description Needs Meets Exceeds Not

Improvement Requirements Requirements Applicable
I. Personal Profile

II. Patient History / Comorbidities

III. Admitting Diagnosis Pathophysiology &

Diagnosis(es) Abstract Forms

#1. Admission diagnosis abstract:

#2. Comorbid or other diagnosis abstract:

#3. Comorbid or other diagnosis abstract:

IV. Current/Recent Diagnostic

Tests/Studies/Procedures

V. Current Nursing Interventions

VI. Laboratory Test Results

VII. Medications

VIII. Specific Therapeutic Communication Skills/

Techniques

IX. Medical Complications/Nursing Issues

X. Teaching Needs

XI. Nutrition Support

XII. Developmental Information

XIII. System Assessment-Clinical Day

XIV. SOAP NOTE / Progress Note / PES Note.

(Facility Specific Progress Note Policy)

XV. NURSING CARE PLAN

XVI. JOURNAL

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