Prep Sheet
Content
Patient Initials: Rm #:
Cabrillo College Clinical Clini cal Preparation Sheet Sheet - Part Part 1
Student: Date(s) of Care:
Pathophysiology On the back of this sheet or a separate paper, describe in writing or by drawing a concept map the pathophysiology of the chief complaint and the admitting admitting disease process. Include, if you can, how the patient's other chronic illnesses illnesses or conditions PMH (prior (prior medical history) history) contributes to or affects the primary diagnosis. Compare and contrast your patient to the textbook description of the clinical manifestations, diagnostic procedures, medical and nursing care. Date of admission: Chief complaint: Age: Doctors: Admitting diagnosis:
Allergies: Diet:
Date and type of surgery:
Activity Order: Order: Code Status: lab ordered for date(s) of care :
PMH / Chronic conditions:
IV type & site: Other disciplines involved in care of client (e.g. respiratory, physical or occupational therapy, social service, etc.)
IV solution & rate: Other:
Significant abnormal lab values
Why are they abnormal?
How are they being corrected?
1. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 2. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 3. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 4. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 5. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 6. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________
Diagnostic Dia gnostic Procedures
Purpose (if unfamiliar to you)
Patient Prep & Post Care
Results
1. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 2. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 3. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ Tubes, lines, drains or treatme treatments nts
Purpose (if unfamiliar to you)
Nursing assessment/ assessment/documentation documentation
1. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 2. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 3. _______________________________________________________ _______________________________________________________________________________________________ ________________________________________ 4. _______________________________________________________________________________________________
8/23/2005
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Patient Initials: Rm #:
Student: Date(s) of Care:
Clinical Preparation Sheet - Part 2 2 I am going to pay special attention to:
What teaching will my pt. require? How do I prepare for it? (What resources are available in the hospital (videos, brochures, etc.)
Time Management Report – ___
Notes / To Do List / Questions/ Skills to review/ Words to look up ____ - ____
Quick assessment Airway Breathing Circulation Intake Output ain P Safety
Areas I was strong in:
8/23/2005
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End-of-Shift
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list
Charting MARs Signatures I&Os Goodbye to pt. Report to RN Pockets
No patient ID on papers
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Resources for Prep: Prep: M/S textbook; Skills book; Lecture notes; Medical Dictionary Pathophys. Book; N. Dx. Book; Lab/Dx book; Drug/Pharm Book; Internet Internet;; Hospital procedure manual man ual ; Other:
Post-Clinical Self-evaluation Areas needing improvement: improvement:
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Patient Initials: Rm #:
Student: Date(s) of Care:
Clinical Work Sheet Neuman System Variables Psychological
As sessm ses sm ent Date/Time
Physiological (Systems Review) NEURO
Coping methods Mood/Affect
LOC Wakefulness
Cognitive abilities Attitudes Values Memory Thought content Hallucinations Agitation
Orientation Speech Follows commands Pupils Swallow
Ht/Wt INTAKE Type
MUSC-SKELETAL Extremity Strength Sensation ROM Activity / Gait
Developmental Developmental stage Maturational events Significant life events Transitions stressors Role
Last BM _________ Dressings & Wound Care
Edema Capillary Refill Jugular Vein Distention
Access to healthcare Family resources Economic status Family structure Ethnic-cultural Language Literacy
PULM O2 amt/mode O2Saturation Respiratory effort Lung Sounds Cough/Secretions Chest Tubes
Spiritual Religious beliefs Spiritual values Hopefulness
FSBG
Safety Issues Issues Restraints
Abdomen Bowel Sounds Appetite / % eaten
(start systems review) SKIN SKIN Color/Temp/Turgor Braden score/stage Hydration IV site
Time
Fall precautions
Nausea/vomiting Tube feeding: type/site Other tubes/drains GU Urine description Catheter
Time
Time
Insulin
Other Treatments
GI
Physiological
Amt
OUTPUT OUTPUT Type Amt
CARDIO Heart Sounds Pulses
Sociocultural
Vital Signs
As ses sm ent Asses Date/Time
HOH Poor vision other
Today’s lab results
BP HR RR Temp Pain 8/23/2005
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