RELATED LEARNING EXPERIENCE

REQUIREMENTS FOR MEDICAL

AND SURGICAL WARD AREAS

Name:_________________________________ Section:__________________
Area of Exposure:_______________________ Date of Exposure:__________
Concept:________________________________________________________
Clinical Instructor:________________________________________________
I. GENERAL AND SPECIFIC OBJECTIVES

A. General Objectives (Specify the concept of duty)

B. Specific Objectives (Exact tasks written in order of priority)

1._______________________________________________________________
2._______________________________________________________________
3._______________________________________________________________
4._______________________________________________________________
5._______________________________________________________________
6._______________________________________________________________
7._______________________________________________________________
8._______________________________________________________________
9._______________________________________________________________
10.______________________________________________________________

II. PATIENT’S DEMOGRAPHIC DATA

Patient’s Initials:

Sex: Age: Date of Birth: Marital Status:

Address:

Occupation: Religion:
Weight (kg): Height (m):
Date and Time of Admission:

Chief Complaint:

Admitting Diagnosis:

Admitting Physician:
III. PATIENTS MEDICAL HISTORY
A. History of Present Illness ( A narrative detail of the current admission in
chronological order)

B. Past Health History

Previous Hospitalizations/Surgery/Ilness (include date, hospital, diagnosis, procedure):
1.
2.
3.
4.
5.
Diagnosed Chronic Illness (specify):

Immunizations (complete or incomplete, specify):

Obstetric History (if applicable):

Allergies (specify):

Other Important Information:

C. Family Health History (Genogram with brief narrative explanation)

 D. Psychosocial History
Brief Description of Lifestyle and Relationship with Family and Peers:

Vices and Addictions (Provide a brief history, including smoking, alcohol, illegal drugs):

Employment History (all employment from beginning to the current):

Current Stage in Erickson’s Psychosocial Theory (discuss any positive or negative

resolution):

IV. PHYSICAL ASSESSMENT/EXAMINATION (Encircle and/or provide the

 information based from your assessment findings)
Vital Signs
Temperature: Pulse: Respiration: Blood pressure: O2 Saturation: Pain Score:
GENERAL SURVEY
How does the Age: DOB: Sex: Male / Female
client look like? Body Build: Thin Cachectic Obese Within Normal Limits
Height: _________ Weight: ______________
Well groomed Poorly Groomed
Facial Expression: Anxious Happy Sad Angry
NEUROLOGICAL
(LOC) Level of Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate
Consciousness Decorticate
Oriented x 4: Person Place Time Event
Response to touch/voice
Eyes Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/
Blind
Pupils Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light
Consensual
Pupil size before light ______mm Pupil size after light ______mm
Ears Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen
Drainage
Extremities Hand grips +1 +2 +3 +4 +5 equal unequal
Foot pushes +1 +2 +3 +4 +5 equal unequal
Cranial Nerves I (smell)
II(vision)
III+IV+VI (eye movement)
V (sensation of face/oral)
VII (facial movement/taste)
VIII (hear/balance)
IX (taste/swallow)
X (chew/gag/speech)
XI (shrug/turn head)
XII (tongue movement)
Pain Character Onset Location
(COLDSPA) Duration Severity Pattern
Associated Factors

CARDIOVASCULAR
Skin/Mucous Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic
Membranes
Radial and Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R) Absent (L/R)
Pedal Pulses
Apical R (2 people simultaneously) Apical and Radial Pulse Deficit
adial Pulses
Carotid Pulses (DO NOT TAKE AT SAME TIME) Right Left Thrill Bruit
Capillary Refill Normal (<3 Sec) ______sec
Jugular Neck Not visible Visible
veins
Edema Absent Present: location +1 +2 +3 +4 Anasarca Pitting Non
Pitting
Calf Tenderness Denies Positive Homan’s sign R L calf size R____ L_____ (team leader or charge nurse notified)
Heart Regular Irregular Murmur Extra sounds Strong Faint Muffled
Rhythm/Sounds
-S12 Telemetry: rhythm ___________________ Pacemaker Defibrillator location
IV Fluids Solution_______________ Rate __________ml/hr Infusion Pump
Site location (be specific) ______________________________________
Site appearance: Clear Edema Erythema Tender Pallor
Dialysis access: type __________ Thrill Bruit Location:___________
Appearance:____________
RESPIRATORY
Respirations Regular Irregular Even Uneven Unlabored Labored Symmetrical
Asymmetrical
Lung Sounds Clear LUL RUL LLL RLL RML Anterior Posterior
Wheezes location__________ Rales/crackles location__________
Rhonchi location ________
Nasal flaring Sternal retraction Intercostal retraction
Do lung sounds improve with cough and deep breath (y/n)?
Cough None Nonproductive Dry Moist
Productive Sputum: amount _______________
color_______________ frequency___________
Oxygen Room air Pulse ox ______ O2 at_____L/min
Nasal Cannula Mask Tent CPAP
BIPAP
Respiratory Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds # of times______
Treatments HHN medication Bipap
Ventilator? TV rate 02% other

GASTROINTESTINAL
Oral Teeth Dentures Caries Dysphagia
Mucous Membranes: intact moist dry pale leukoplakia
Abdomen: Inspect Soft Round Flat Scaphoid Obese Firm Hard
Auscultate Percuss Nondistended Distended Tender Non Tender
Palpate Location:
Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive
Absent
NGT/GT/JT None Type of tube _____ patent nonpatent
Suction: low high Color of drainage ______________
Amount____________________
Bowel Movement Continent Incontinent last BM______________ Color
_______________ Size_________________ Consistency_________________
 Ostomy Stool
Nutrition Diet___________ % eaten Breakfast____ Lunch_____ NPO?
Why___________
Self feed Needs assistance Thickened liquids: honey nectar pudding Tube
Feed_________________
GENITOURINARY
Urine Continent Incontinent Catheter type _______________ Patent Nonpatent
Color_________________ Clear Cloudy Sediment Burning Frequency
Intake and Output PO/Oral/Tube Feed intake____________ IV intake____________ Urine output_________ Other
output
Fluid restriction Total I&O + /- ________________
Genitalia Male Female vaginal discharge LMP Post partum
MUSCULOSKELETAL
Mobility ADLs independent or assisted with _________________________________________________
Muscle Treatment None Cast Brace Splint Location Elevate
Traction – type: _________________________ Traction weight:
_________________________
CMST Circulation: color, pulses, cap refill Motion Sensation Temperature
RA LA
RL LL
Antiembolitic Hose:knee/thigh
Contractures Not present Present – which extremity? What % decreased?
Amputation No Yes Location _______________________________
ROM AROM AAROM PROM CPM Limited
location___________________
Mobility Turns self Sits independently Dangles Stands independently Walks
independently
Ambulatory assistance: Gait belt Cane Walker Crutches Braces Wheelchair
Gerichair
Walks: distance frequency tolerance PT OT RNA
Risk for falls Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side Rails Mechanical Lift
Slide Board

INTEGUMENTARY
Appearance Intact Color___________ Pallor Rash Bruise Lesions Scar Location
__________________
Turgor_____ seconds Site___________
Skin Warm Hot Cool Cold Dry Moist
Wound Dressing None Surgical site – Location Well approximated Sutures Staples
Steristrips
Dressing: Dry/intact Non-intact Change: Yes No
Pressure Ulcers
Drainage: Color Amount___________ Odor_________
Wound appearance: Drain type _________ Amount______

Stage Location Size Tunneling Eschar Slough

Stage Location Size Tunneling Eschar Slough
Stage Location Size Tunneling Eschar Slough
ISOLATION (if applicable)
Type Culture Site

PSYCHOSOCIAL
Behavior Cooperative Uncooperative Pleasant Withdrawn Combative
Other_______________
Restraints None Chemical Physical: type location

CMST of extremity
RA LA
RL LL
Frequency Checked________________
Language Spoken _______________________

B. General Summary of Physical Assessment/Examination Findings

(Provide a narrative summary of all the findings and correlate with the
diagnosis of the patient)

V. ANATOMY AND PHYSIOLOGY

(Draw and label the affected organ/system and provide a brief discussion of
its function/uses)
VI. PATHOPHYSIOLOGY
(Trace the disease process of the patient’s diagnosed condition. Provide a
brief discussion after the tracing)

Reference:
VII. LABORATORY AND DIAGNOSTIC STUDY
Date Type of Exam Patient’s Normal Values Significance/
Results Interpretation
Hematology
Specific
Examination:

______________
Urinalysis

Stool
Examination

Imaging Studies
Specific:

______________
*Please use the back portion for additional laboratory and diagnostic study.
 VIII. DRUG STUDY
Drug Classification Mechanism Indication Contraindic Adverse Nursing
of Action ation Effects Responsibil
ities
Generic
Name:

Brand
Name:

Dosage:

Route:

Frequency:

Timing:

* Please use the back portion for additional medications for drug study. Follow the
prescribed format.

IX. PROBLEM PRIORITIZATION (at least 5)

Problem Justification
1.

2.

3.

4.

5.

X. NURSING CARE PLANS

Problem 1:_______________________________________________________
Defining Nursing Scientific Plan of Care Nursing Rationale
Characteristics Diagnosis Analysis Interventions
Subjective: Short Term: Independent:
1. 1.
 2. 2.
Objective: Long Term:

3. 3.

4. 4.

5. 5.

Collaborative:
1. 1.

2. 2.

3. 3.

4. 4.

Reference: Reference: Reference:

Problem 2:_______________________________________________________
Defining Nursing Scientific Plan of Care Nursing Rationale
Characteristics Diagnosis Analysis Interventions
Subjective: Short Term: Independent:
1. 1.

2. 2.
Objective: Long Term:

3. 3.

4. 4.

5. 5.

Collaborative:
 1. 1.

2. 2.

3. 3.

4. 4.

Reference: Reference: Reference:

Problem 3:_______________________________________________________
Defining Nursing Scientific Plan of Care Nursing Rationale
Characteristics Diagnosis Analysis Interventions
Subjective: Short Term: Independent:
1. 1.

2. 2.
Objective: Long Term:

3. 3.

4. 4.

5. 5.

Collaborative:
1. 1.

2. 2.

3. 3.
 4. 4.

Reference: Reference: Reference:

XI. DISCHARGE PLANNING

General Case of the Patient:

Subjective Data

Objective Data

Assessment/Nursing
Diagnosis
Planning

Intervention
Activity

Medication

Environment

Treatment
 Health Teachings

Outpatient Referral

Diet

Evaluation

XII. Further Readings (News and recent updates related to the diagnosis or
management of the patient)

Reference: