CLARKSON COLLEGE DIVISION OF NURSING BACCALAUREATE NURSING PROGRAM CLINICAL FACE SHEET

PATIENT INITIALS: ADMIT DATE: PATIENT AGE: ETHNICITY: CODE STATUS: Code/DNR ADVANCED DIRECTIVES: Living Will/POA

ALLERGIES:

DIET WITH RATIONALE:

ADMISSION/CHIEF COMPLAINT:

PATIENT HISTORY / OTHER MEDICAL DIAGNOSIS:

PATIENT SUPPORT SYSTEM:

CULTURAL/SPIRITUAL PREFERENCES:

CURRENT VITALS:

PRE-LAB
DATE:

CLINICAL DAY #1 0800 DATE:

CLINICAL DAY #1 1200 DATE:

TPRBP -

ALL CURRENT MEDS (NotPRNs unless receiving frequently): MED DOSE ROUTE TIME INDICATION

IV SOLUTIONS:

PROCEDURES/EQUIPMENT: Activity/Mobility/Assistive Devices NG/PEG/Dobhoff Colostomy/Ileostomy Chest Tube Urinary Drain Wounds Wound Drains Dressing Changes ECG/Telemetry Dialysis Access Neuro Checks O2 - FIO2 SAT Monitor-Oximeter IVs Central Line Saline Lock PICC Mediport ISOLATION TYPE & RATIONALE:

DIABETES/TYPE: INSULIN / ORAL ANTIDIABETICS:

BLOOD GLUCOSE MONITORING:

PATHOPHYSIOLOGY FORM DIRECTIONS:

Students may utilize information obtained from a textbook or journal article to thoroughly complete the pathophysiology worksheet each week. Correlate the textbook data to that of your actual client data. Ask: How do my clients signs and symptoms correspond with the textbook diagnosis? The pathophysiology worksheet is available as a template for those students who would prefer to complete it as a computer generated document, you are not limited to the space provided.

Disease: Text Book Data Definition/Etiology: Actual Client Data Onset of Disease:

Signs & Symptoms:

Client Signs & Symptoms:

Diagnostic Tests:

Diagnostic Tests with Results:

Treatments:

Current or Recent Treatments/Medications:

Commonly Used Medications:

Potential Outcomes of Disease Process:

Briefly discuss the impact of the disease process on the clients ability to function:

Reference:

Lab & Diagnosis Test

Pt. Initials: Test
Normal Admit Date

Diagnosis:
PreLab Date Clinical #1 Date Clinical #2 Date

Patient Interpretation State Top 3 reasons Why Abnormal

HEMATOLOGY WBC RBC HGB HCT NEUT SEG BAND LYMPH MONO EOS BASO PLT SED RATE 4-11 4-6 12.517 37-50 1-7.7 40-70 0-6 1-3.5 .2-1.1 0-.4 0-.1 150450 0-15
Date Date Date Date

COAGULATION PT INR PTT 22.235.5 10.113.3

INR less than 2 w/o anticoagulant 2 -3 with anticoagulant

Test

Normal

Admit Date

PreLab Date

CHEMISTRY NA K CI CO2 Creatinine

Urea Nitrogen (BUN)

Clinical #1 Date

Clinical #2 Date

Patient Interpretation

137145 3.6-5 98107 22-30 .7-1.5 9-20 70110 1.62.3 38126 8.410.2 .1-1.3 0-.4 6.38.2 3.5-5 15-4.6 11-66 100250 30170 .3-4 0-1.4 0-1

Glucose Mag Phos Ca Total Bilirubin Direct Bilirubin Total Protein Albumin AST ALT LDH CK CKMB Troponin I C-Reactive Protein

Test Osmolality Amylase Lipase Cholesterol HDL LDL Triglycerides

Normal

Admit

PreLab

Clinical #1

Clinical #2

Patient Interpretation

275305 30110 23300 150200 40110 0-100 0-150

Date Date Date Date

BLOOD GASES Arterial pH PCO2 PO2 HCO3 U/A Yello wAmbe r Clear 1.0161.03 5-8 -

ABG Interpretation

Date

Date

Date

Date

Color

Appearance Specific gravity pH Leukocyte Esterase Nitrates Protein Glucose

Test Ketones Bacteria Urobilinogen Bilirubin Casts Crystals RBC WBC

Normal

Admit

PreLab

Clinical #1

Clinical #2

Patient Interpretation

2.1 -

0-2 0-2
Date Date Date Date

OTHER LABS (C/S) Culture Sensitivity Drug Screen Blood Alcohol Medication Serum Level

DIAGNOSTIC TESTS
Exam and Date CXR CT Scan INTERPRETATION