BRECKINRIDGE SCHOOL OF NURSING AND HEALTH SCIENCES

AT ITT-TECHNICAL INSTITUTE
Student:
Patient Initials:

Facility:
Room #:

BRIEF HISTORY MEDICAL/SURGICAL HISTORY:

CURRENT ILLNESS & PATHOPHYSIOLOGY:

SOURCE:
CLINICAL MANIFESTATION OF DISEASE:

SOURCE:
CURRENT MODALITIES OF TREATMENT:

SOURCE:

Instructor:

ISOLATION: Age/Gend:

Code Status:

Allergies:

SCIENCES

Date:
Allergies:

PULMONARY
Oxygen Device & Flow: N/A

SpO2: N/A

Breath Sounds/Effort: WNL

IS/Flutter Valve/CPT: N/A

ABG RESULTS: N/A

CXR Date & Finding: N/A

PFT Date & Finding: N/A

Ventilator Type: N/A

Tube Type & Size: N/A

Tidal Volume: N/A

Fi02: N/A

Mode: N/A

RSV: N/A

PEEP/CPAP: N/A

Intubate>1 TIME: N/A

VAP: N/A

ChestTubes/Location/Drainage: N/A

Labs: N/A

Diagnostic Tests:

Medications:

Nursing Diagnosis:

Teaching:

Landmark: N/A

Suction or H2O: N/A

Sputum Color/Consistency: N/A

Insertion Date: N/A
Rate: N/A
Weaning: N/A
Secretions (Amount/Color): N/A

PSYCHOSOCIAL & SPIRITUAL / CULTURAL

Family / Significant Other: son/ married
Emotional Status:

Calm: X

Contact Number: N/A

Sad:

Withdrawn:

Angry:

Support System (Family, Spouse, Church, etc): N/A

Irritable:

Verbal:

Lives With: spouse

Established Services (HH, Hospice, IV Infusion Therapy, etc): N/A

POA: N/A

Marital Status: M-X

Religious / Cultural Beliefs: N/A

Language
Primary: English Secondary: N/A

Recent Lifestyle Changes: N/A

Able to Read w/o Assistance: Y X

Nursing Diagnosis:

Teaching:

Financial Assistance Needed: Y

X

Nursing Home: N/A

Need for Interpreter:

N Medication Assistance Needed: Y

NX

NX

Transportations Assistance
NX

Anxious:

Fearful:

NX

tations Assistance Needed:

CARDIOVASCULAR
Heart Rate:

Rhythm: WNL

Last EKG (Date, Rate, Rhythm): N/A

BP:

Heart Sounds: WNL

Rt Arm: X

Pacemaker/AICD: N/A
Labs:

Na+:

K+:

Thyroid Profile:

If yes, Type & Settings: N/A

Mg+:

Cl-:

Free T4 n/a

T3

Ch+:
n/a

PO4:

Heart Sounds: WNL

PT/INR:

aPTT:

TSH n/a

Cardiac Enzymes: N/A

1st n/a

2nd n/a

3rd n/a

Hemogram: N/A
Hgb/Hct:

RBCs:

WBCs:

Differential:
Hemodynamincs: N/A
CVP:

n/a

PA:

n/a

PAOP:

n/a

CO: n/a

CL:

n/a

SVR: n/a

SVO2:n/a

Procedures: N/A
IV Line Insertion (Date, Size, Location, Landmark, Type): l
Peripheral Pulses & Assessment: WNL
R Radial

L Radial

Edema

R Pedal

L Pedal

Edema N/A

Diagnostic Tests:

Medications:
Nursing Diagnosis:

Teachings:

R Femoral

L Femoral X

Edema N/A

MAP: n/a

Lt Arm:
Presence of JVD: N/A

Platelets:

GASTROINTESTINAL
Abdomen: Flat & symmetric w/ no masses
Bowel Sounds:
LUQ: X RUQ: X LLQ: X RLQ: X
Ostomy (Size & Location): N/A

NX

Last BM (Date):
Stool Description:
Size: N/A
Insertion Date: N/A

NGT/OT/GT/JT/: N/A
Clamped/Suction: N/A
Dressings: N/A

Drains: N/A
Nutritional Consult:

N/V: Y

NX

Recommendations: N/A

Labs:
SGOT
Diagnostic Test & Findings:

Medication:

Nursing Diagnosis:

Teaching:

SGPT

AMYLASE

LIPASE

ALBUMIN

Location:
N/A

on:

Diet: N/A
NPO
TPN: N/A
Tube Feeding: N/A
Secretion:
N/A

GENITOURINARY/RENAL/REPRODUCTIVE
Foley/Urostomy & Insertion Date: N/A

Urine Color/Odor/Character: Yellow Dialysis/Type/Frequency: N/A

Intake/Output in Last 24 hrs: N/A

Bladder Distention:
NX

Penile/Vaginal Discharge: N/A

Reproductive Abnormalities: N/A

Voiding Pattern: WNL

Diuretics: Y N X
Edema: N/A

LABS:
BUN:

Creatinine:

Urinalysis:
DIAGNOSTIC TESTS:

MEDICATIONS:

NURSING DIAGNOSIS:

TEACHING:

CO2:

HCO3:

K+:

Mg+:

PO4:

Urine Protein:

Urine Culture:

LMP: N/A

/A

Continent: Y X

HEAD/NECK/NEURO
SPEECH: WNL

LOC: Alert and Orient x 3

EYES/PUPILS: PERRLA

NOSE: No deformity. Nares patent. GAIT: Unsteady

Mucosa pink; no septal deviation or
perforation

MOUTH: Can clench teeth, Mucosa EARS/HEARING: No masses,

GRIPS: =
and gingivae pink, no masses or
lesions, tenderness, or discharge.
Bilaterally
lesions
Whispered words heard bilaterally.
R X LX

PSYCHIATRIC HX: N/A

LEG STRENGTH:
WNL

NECK/TRACHEA: Supple
w/ full ROM, no pain;
trachea midline

CAROTIDS: Pulses
2+ and equal
bilaterally

DTR:
Y X

LABS:
Na

NH3

Ca+

BLOOD CULTURES:

Glucose

N/A

WBC

LFT

GSCS:

HEARING AIDS:
DIAGNOSTIC TESTS:

MEDICATIONS:

NURSING DIAGNOSIS:

UPPER

CKMB
DENTITION:

DENTURES:
L

TEACHING:

UA

GLASSES:
LOWER

N/A
CERVICAL/NECK LYMPH
NODES: No
lymphadenopathy or masses;
Symmetric
SEIZURES:
Y

NX

SKIN / SAFETY / MOBILITY

Braden Score:

Restraints/Type: N/A

Physical Therapy: N/A

Fall Risk Score:

Assistive Devices: N/A

Activity: N/A

Wound Care: N/A

Nutritional Status: N/A

Turgor: Good, no lesions

HOB: N/A

MEDICATIONS:

NURSING DIAGNOSIS:

TEACHING:

Labs:

Protein

7.9

Albumin 4.3

Turn Schedule: N/A

Personal Hygiene: Good

Safety Action Plan: N/A
Color/Temp:
Specialty Bed / Mattress: N/A

MUSCULOSKELETAL
ROM:
LU: WNL RU:WNL

Height: 1

Weight:

Weakness: LU N/A RU N/A LL N/A

Extremity Sensation:

Gait:

Pain:

Fractures: N/A

LU: WNL RU: WNL LL: WNL RL: WNL

Pain Location:

Rating:

Labs:
Diagnostic Tests:
Medications:

Nursing Diagnosis:

Teaching:

LL: WNL RL: WNL

Pain Scale Used:

A RU N/A LL N/A RL N/A

ENDOCRINE
Blood Glucose Checks Frequency: N/A

Last 24 Hours:
0700:

N/A
1100:

1600:

2100:

Insulin Orders: N/A

Test/Labs: N/A
HgA1c:

n/a

CO2: 22

Diagnostic Tests: N/A

Medications: N/A

Nursing Diagnosis: N/A

Teaching: N/A

TSH: n/a

Free T4: n/a

T3: n/a

LFT:

n/a

0200:

0300:

Breckinridge School of Nursing

Diet Card
Diet:
Rationale for Diet:

Foods Allowed:
Foods Disallowed:
Tube Feeding:
Formula:
Indications/Use:
Feeding Administration:
Bolus/Syringe Frequency:

Amount:

Cyclic Frequency:

Amount:

Continuous:

Amount:

Flush:

Amount:

Frequency:

Free Water:

Amount:

Frequency:

Total Calories in 24 Hrs:

Total grams of protein in 24 hrs:
Total milliliters of water in 24 hrs:
Parenteral Nutrition: n/a
Amount:
Formula:

Infusion Rate:
Dextrose:

Amino Acids:

Multivitamins:

Trace Elements:
Electrolytes:
Other Additives or Medications in bag (for ex: Insulin):

Lipids: Amount: n/a

Frequency: n/a

Rate: n/a

Daily Weight: n/a

FSBG/Times: n/a

Sliding Scale: n/a

ng

vitamins:

n/a

g Scale: n/a

Breckingridge School of Nursing

Clinical Medication Sheet
Student:
Drug

Client's Initials:
Classification & Mechanism of Action

Clinical Week:
Major Side Effect & Contraindications

Drug (trade&generic name):

Function Class:
Chemical Class:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

Dose:
Route: (give timing for IV push &
IVPB drugs):

Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Function Class:
Chemical Class:
Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Frequency:
Rationale for client:

Function Class:
Chemical Class:
Action:

Nursing Consid

Date:
ing Considerations

dote:
hing:

dote:
hing:

dote:
hing:

Breckingridge School of Nursing

Clinical Medication Sheet
Student:
Drug

Client's Initials:
Classification & Mechanism of Action

Clinical Week:
Major Side Effect & Contraindications

Drug (trade/ge):

Function Class:
Chemical Class:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

Dose:
Route: (give timing for IV push &
IVPB drugs):

Action:

Frequency:
Rationale for client:
Drug :
Dose:
Route: (give timing for IV push &
IVPB drugs):

Function Class:
Chemical Class:
Action:

Frequency:
Rationale for client:
Drug (name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Frequency:
Rationale for client:

Function Class:
Chemical Class:
Action:

Nursing Consid

Rationale for client:

Date:
ing Considerations

dote:
hing:

dote:
hing:

dote:
hing:

Breckingridge School of Nursing

Clinical Medication Sheet
Student:
Drug

Client's Initials:
Classification & Mechanism of Action

Clinical Week:
Major Side Effect & Contraindications

Drug (trade&generic name):

Function Class:
Chemical Class:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

Dose:
Route: (give timing for IV push &
IVPB drugs):

Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Function Class:
Chemical Class:
Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Frequency:
Rationale for client:

Function Class:
Chemical Class:
Action:

Nursing Consid

Rationale for client:

Date:
ing Considerations

dote:
hing:

dote:
hing:

dote:
hing:

Breckingridge School of Nursing

Clinical Medication Sheet
Student:
Drug

Client's Initials:
Classification & Mechanism of Action

Clinical Week:
Major Side Effect & Contraindications

Drug (trade&generic name):

Function Class:
Chemical Class:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

CNS:
CV:
HEMA:
INTEG:
GI:
GU:
EENT:
CONTRAINDICATIONS:

Antedote:
Teaching:

Dose:
Route: (give timing for IV push &
IVPB drugs):

Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Function Class:
Chemical Class:
Action:

Frequency:
Rationale for client:
Drug (trade&generic name):
Dose:
Route: (give timing for IV push &
IVPB drugs):

Frequency:
Rationale for client:

Function Class:
Chemical Class:
Action:

Nursing Considera

Date:
ursing Considerations

ntedote:
eaching:

ntedote:
eaching:

ntedote:
eaching:

Breckinridge School of Nursing

Lab Profiles (Highlight Abnormal labs)
Diagnostic Study

Normal Findings

Hgb
Hct
RBC
MCV
MCH
MCHC
RDW
WBC
Neutrophils
Bands
Lymphocytes
Monocytes
Esonophils
Basophils
Abs.Gran.Ct.
Platelet
MPV
Metabolic Panel
Sodium (Na)
Potassium (K)
Chloride (Cl)
CO2
Anion Gap
Calcium
Magnesium (Mg)
Glucose
BUN

14-18 g/dL
36-48%
4.2-5.4 mill/mm3
82-98 fl
26-31 pcg
32-36%
10.9-14.1%
1.8-7.0 K/mm3
35-90%
0-9%
20-40%
0-14% (5.5-11.7)
0-8%
0-2%
2500-6000
150-450 K/ul
7.4-10.4 fl
135-145 mEq/L
3.5-5 mEq/L
95-110 mEq/L
23-31 mEq/L
5-15 mg/dL
8.5-10.5 mg/dL
1.5-2.0 mEq/L
85-125 mg/dL
5-25 mg/dL

Student Yarbrough
Clinical Week
Client Results/Date

Client Results/ Date

Creatinine

0.7-10.4 mg/dL

Client Initials:
Date
Clinical Significance

Breckinridge School of Nursing

Lab Profiles (Highlight Abnormal labs)
Diagnostic Study
Arterial Blood Gases
pH
PCO2
PO2
Bicarbonate
Base excess
O2 Sat
Ionized Calcium
Liver Function Tests
Bilirubin Total
Alkaline Phosphate
AST (SGOT)
ALT (SGPT)
Total Protein
Albumin
Pre-Albumin
Urinalysis
Cast
Color
Turbulance
Specific Gravity
pH
Nitrate
Glucose
Keytone
Urobilinogen
Bilirubin Total
(urine cont.next pg)

Normal Findings

Student
Clinical Week
Client Results/Date

Client Results/ Date

----------------------

----------------------

------------------

----------------------

----------------------

-----------------

---------------------

-----------------

------------------

Client Initials
Date
Clinical Significance

Breckinridge School of Nursing

Lab Profiles (Highlight Abnormal labs)
Diagnostic Study

Normal Findings

Student
Clinical Week
Client Results/Date

Client Results/ Date

Urine WBCs
Urine RBCs
Urine Protein
Leuk Estrase
Urine Blood
Urine Bacteria
Thyroid Tests
TSH
Total T4 (Thyroxin Screen)
Free T4 (Thyroxin)
Cardiac Enzymes
CPK
CKMB-ISO
CKMB-Index
Troponin T
Troponin I
BNP
Homocystine
CRP

---------------------

-----------------

-----------------

----------------------

------------------

------------------

Client Initials
Date
Clinical Significance

Breckinridge School of Nursing

Student yarbrough

Lab Profiles (Highlight Abnormal labs)

Clinical Week

Diagnostic Study
Tests

Other Normal Findings

Vitamin B12
Total PSA
Uric Acid

Prothrombin Time (PT)

Partial Thromboplastin Time
(PTT)

International Ratio (INR)

Fibrinogen

Client Results/Date

Client Results/ Date

Patient Initials:
Date
Clinical Significance

Breckingridge School of Nursing Clinic Tool: Diagnostic Studies

Student:
Diagnostic Study

Client's Initials:
Normal Findings & Indication for Study

Clinical Week:
Explanation of Test/Procedure & Client Clients Test Results & Clin
Care

Date:
nts Test Results & Clinical Significance

Breckingridge School of Nursing Clinic Tool: Diagnostic Studies

Clinical Care Plan
Student
Assessment
Must Support NANDA
S: Patient says " I can't stay out of the
bathroom and it is very painful when I
go".

Client Initials:
Nursing Diagnosis
Dx: Diarrhea

R/T: Ulcerative Colitis

AEB: frequent loose stool

S/T:
Desired Outcomes / Goals
SMART
O:
Blood in stool
pain of
9/10 in abdomen.
BP 143/100
1. Patient will maintain a perirectal
temp-102.7
area free of irritation by end of 8
hour shift.
2.
Patient will state relief from
cramping with a tolerable pain level
of 2/10 by end of 8 hour shift.
3. patient will have
negative stool cultures for blood by
end of 8 hour shift.

Clinical Week:
Nursing Interventions
1 Assess / 1 Teach / 3 or more actions
1. Obtained a stool specimen
2.
Assessed for signs of skin breakdown
around perirectal area.
3.Teach patient how to stay
hydrated.

Rationale
1. obtained stool specimen so that
lab could test for ocult blood.
2. Patient should ha
brief changed immediately followi
Bowel movement to avoid skin bre
down.
3.It is common for
patients with diarrhea to be
dehydrated.

Date:

e
men so that
blood.
nt should have
tely following
oid skin break
mon for
o be

Evaluation
1. Patient remained free
of Perirectal area
irritation at end of 8 hour
shift. Goal met
2. Patient stated relief
from cramping with a
tolerable pain of 2/10 at
end of 8 hour shift. Goal
met
3.Patient
had negative stool
cultures at end of 8 hour
shift. Goal met

Breckinridge School of Nursing

Student:

Date:

Week:

PI:

Notes Must Be In Chronological Order and Cover Entire Day Include Complete Head to Toe Assessme

0700
0800
0900

1000

1100
1200

1300
1400
1500

1600
1700

ek:

PI:

lete Head to Toe Assessment