Georgia Northwestern Technical College Practical Nursing Program CLINICAL DAILY ASSESSMENT WORKSHEET FOR MODULES I-IV STUDENT: CLINICAL INSTRUCTOR:

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1 Georgia Northwestern Technical College Practical Nursing Program CLINICAL DAILY ASSESSMENT WORKSHEET FOR MODULES I-IV STUDENT: CLINICAL INSTRUCTOR: CLINICAL UNIT: ASSIGNMENT DATES: PATIENT (last initial): M/F: Age: RM#: Race MD (last initial): ALLERGIES: LATEX: OTHER: CODE STATUS: ADMISSION DATE: ADMITTED FROM: ADMITTING DIAGNOSIS: PRESENTING SIGN/SYMPTOMS: MEDICAL HX: ADL ORDERS: O2 ORDERS (LPM /NC/MASK/CPAP/VENT) RESP TX: CULTURAL/ETHNIC IMPLICATIONS PERTINENT TO CARE: DIET: RATIONALE: HT: WT: NUTRITIONAL CONCERNS: NG: IVF: ADMINISTRATION DEVICE: FOLEY (size/type): INSERTION DATE: DIALYSIS : DRAINS: PAIN ASSESSMENT - Location: Pain scale : Description: Revised 2013 PN Clinical Daily Assessment Packet Page 1

2 NOTES: Revised 2013 PN Clinical Daily Assessment Packet Page 2

3 DIAGNOSTIC TESTS DATE: FINDINGS/ IMPRESSIONS NURSING IMPLICATIONS (if test completed during students care) Pre-procedure Post-procedure SURGERY PROCEDURES DATE: FINDINGS NURSING IMPLICATIONS (if surgery performed during students care) PRE-OP POST-OP PHYSICAL THERAPY NURSING IMPLICATIONS Revised 2013 PN Clinical Daily Assessment Packet Page 3

4 PSYCHOLOGICAL/SOCIAL NEEDS Maslow s Hierarchy Needs (Identify any unmet) Physiological: Safety and Security: Love and Belonging: Self-esteem: Self-actualization: NURSING DIAGNOSES (Complete 5 nursing diagnoses, individualized and prioritized.) Revised 2013 PN Clinical Daily Assessment Packet Page 4

5 4. 5. Revised 2013 PN Clinical Daily Assessment Packet Page 5

6 PLAN OF CARE (POC will be discussed during pre-conference and post-conference.) DATE: DATE: PATIENT TEACHING Revised 2013 PN Clinical Daily Assessment Packet Page 6

7 CBC WBC RBC HGB HCT MCV MCH MCHC RDW Platelet MPV Lymph % auto Mono % auto Neut % auto Eos % auto Baso % auto 0 2 Lymph # Mono # Neut # Eos # Baso # Segs % man Bands % man 0 5 Lymph % man Mono % man 1 6 Eos % man 0 6 RBC Morph Normal WBC Morph Path Review Date: Date: Nursing Implications Results Results (for only (L) or (H) values) Revised 2013 PN Clinical Daily Assessment Packet Page 7

8 CHEMISTRY PROFILE Glucose (mg/dl) Sodium (mmol/l) Potassium (mmol/l) Chloride (mmol/l) Carbon (mmol/l) Urea Nitrogen (mg/dl) 7 18 Creatinine (mg/dl) Calcium (mg/dl) Phosphorus (mg/dl) Cholesterol (mg/dl) < 200 AST/SGOT (U/L) LDH (U/L) Alk Phos (U/L) Bilirubin, Total (mg/dl) Protein, Total (gm/dl) Albumin (gm/dl) Globulin (mg/dl) A/G Ratio (ratio) Uric Acid (mg/dl) Osmolality Anion Gap (mmol/l) Glomerular Filtration Rate GFR >90 DATE: DATE: Nursing Implications Results Results (for only (L) or (H) values) Revised 2013 PN Clinical Daily Assessment Packet Page 8

9 URINALYSIS COLOR CHARACTER GLUCOSE BILI QUALITY KETONES Normal Range SPECIFIC GRAVITY OCC BLOOD URINE PH URINE 5 9 PROTEIN URINE UROBILINOGEN NITRATE LEUKOCYTES MICROSCOPIC EXAM WBCs RBCs EPITHs BACTERIA MUCUS CRYSTALS CASTS YEAST TRICHOMONAS DATE: DATE: Nursing Implications Results Results (for only Abnormal values) C&S (CULTURE & SENTIVITY) Revised 2013 PN Clinical Daily Assessment Packet Page 9

10 ABG LABS Normal Values Date: PH PacCO mm/hg CO2 SAT mm/hg O2 SAT % PaO mm/Hg HCO meq/l Results Nursing Implications Coagulation Profile PT INR APTT Normal Values Results Date: Date: Date: Date: Nursing Implications Revised 2013 PN Clinical Daily Assessment Packet Page 10

11 DATE: INTAKE PO: Fluids ml Meals % IV: TPN: NG: TUBE FEEDING: VOID: FOLEY: NG: MISC: OUTPUT LTC: IV: TPN: TUBE FEEDING: BLOOD: IRRG: DATE: INTAKE PO: Fluids ml Meals % IV: TPN: NG TUBE FEEDING: VOID: FOLEY: NG: MISC: OUTPUT LTC: IV: TPN: TUBE FEEDING: BLOOD: IRRG: Revised 2013 PN Clinical Daily Assessment Packet Page 11

12 PATIENT INITALS: ROOM #: DATE: RUG DRUG DOSE ROUTE ADMINISTERED RATIONALE/ REASON ORDERED SIDE EFFECTS (LIST 3 LIFE THREATENING) PATIENT RESPONSE (V/S, Labs, Measurable Objective Data) Revised 2013 PN Clinical Daily Assessment Packet Page 12

13 Revised 2013 PN Clinical Daily Assessment Packet Page 13