Midlands Technical College

NUR 134 Clinical Paperwork (Level I) Page 1

Student Name ________________

Daily Plan Vital Signs: Frequency _______ S - Situation Date _____________

0700
Pt. norms _____T _____P _____R MD ____________________Age _____ Gender _____
BP ______O2sat _________
Day 1: Admitting Diagnosis __________________________________________________________
0800 Time ____ T _____P _____R ______
BP ______O2sat______ Procedures since Admission ____________________________________________________
0900 Time ____ T _____P _____R______
B - Background Weight _______ Height ______ BMI ________
BP ______O2sat______

1000
BMI Analysis ________________Allergies __________________________________________
Intake & Output
1100
Code Status _____________ Primary Language __________________
Intake
1200
0900
Physical Handicaps _____________________________________________________________
1300
1100
Precautions: Fall PUP Aspiration Spinal Seizure Other ___________
1400 1300

Past Medical Hx:

1500 Isolation: Contact Droplet Other _________
1500
Miscellaneous Data:
Total Intake ________________

Total Output________________
A - Assessment Patient Data Gathering Worksheet Page 2

Cellular Regulation List Labs: (Explain abnormal values on Diagnostics page)

Na: __________ Other Pertinent Lab Data:
Glucose: ______
Type of Fluids allowed BUN:__________
Creatinine:_____
Fluid Restriction Hgb/Hct:_______
WBC: _________
Platelets:_______
Cognition Neuro Status

Oxygenation Pulmonary/Chest tubes/Tracheostomy O2_______ Method ___________ O2 Sat ______ Treatments:

Perfusion: Cardiovascular/Circulation

Elimination Abdomen/Gastro/Ostomy/ Treatments Bowel : BM _____________

Bladder: Voiding _____________ Foley catheter :_____________
Continence: __________________ Briefs/Pads:______________

Nutrition: Diet

Sensation: Sensory Impairments: vision _____ hearing______

Pain location, score:

Method of pain control:

Mobility: Musculoskeletal/PT/OT / Assistive Devices

Protection: Skin/Wounds/Drains/Treatments

Dressing Changes:
Braden scale:
Psychosocial:Emotional state, stressors Sexuality:
 Page 3
**Include this page in clinical paperwork if patient has abnormal lab values or any radiology/diagnostic test
Abnormal Laboratory Values Radiology /Diagnostic Test

Date Test Abnormal Normal Explanation for Nursing Date Diagnostic Tests Impression. Reason Ordered
Patient Value Range abnormal value. Responsibility
 Page 4

Administration Critical Assessments, Adverse

Therapeutic class Explain rationale for THIS
Times Reactions, Nursing Administration &
Medication and medication for THIS client
& Patient/Family Teaching
Action (be specific)
Crushable?
Generic name: Times due

Brand name:
Dose ordered:
Frequency:
Route(s) ordered:
Dosage range for ordered route:
Safe to give? Crushable-

Generic name: Times due

Brand name:
Dose ordered:
Frequency:
Route(s) ordered:
Dosage range for ordered route:
Safe to give? Crushable-

Generic name: Times due

Brand name:
Dose ordered:
Frequency:
Route(s) ordered:
Dosage range for ordered route:
Safe to give? Crushable-

Generic name: Times due

Brand name:
Dose ordered:
Frequency:
Route(s) ordered:
Dosage range for ordered route:
Safe to give? Crushable-
 Medical/Surgical Workup Page Page 5

Medical Condition #1. (Define. Include reference used)

Patient signs and symptoms Textbook/Reference Signs & Symptoms

Pertinent Surgical Procedures Discuss how the patient’s past histories relate to the present condition. If
Define all surgical procedures and any that you are unfamiliar with (Include there is no relation leave the area blank.
reference)

Erikson’s Developmental Stage

 R - Recommendation Clinical Care Concept Map Page 6

Primary Concept: Treatments & Relevant Medications

PatientPresentation:

Related Medical Diagnosis:

_________________________
AssessmentData:

Priority Nursing Assessments:

Worst Case Scenario/Potential

Complications

Relevant Diagnostic
Test & Labs

Patient Problem/Nursing Diagnoses:

1. 2.
 Page 7
Care Plan

Patient Problem/Nursing Diagnosis 1:

1a. Nursing Priority

Outcome: The Patient Will:

Nursing Intervention Rational Patient Response to Intervention

The nurse will do to/with/or for the patient

Evaluation of Outcome: Met/Partially Met/ Not Met. If not met or partially met you must explain why.