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
NOTES: Revised 2013 PN Clinical Daily Assessment Packet Page 2
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
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.) 1. 2. 3. Revised 2013 PN Clinical Daily Assessment Packet Page 4
4. 5. Revised 2013 PN Clinical Daily Assessment Packet Page 5
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
CBC WBC 4.8 10.8 RBC 4.7 6.1 HGB 14 18 HCT 42 52 MCV 80 94 MCH 27 31 MCHC 33 37 RDW 11.5 14.5 Platelet 130 400 MPV 7.4 10.4 Lymph % auto 20.5 51.1 Mono % auto 1.7 9.3 Neut % auto 42 75 Eos % auto 0.1 4.5 Baso % auto 0 2 Lymph # 1.5 4.0 Mono # 0.11 0.59 Neut # 1.4 6.5 Eos # 0 0.7 Baso # 0 0.2 Segs % man 50 70 Bands % man 0 5 Lymph % man 20 40 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
CHEMISTRY PROFILE Glucose (mg/dl) 70 100 Sodium (mmol/l) 140 148 Potassium (mmol/l) 3.5 5.0 Chloride (mmol/l) 100 108 Carbon (mmol/l) 21 32 Urea Nitrogen (mg/dl) 7 18 Creatinine (mg/dl) 0.6 1.3 Calcium (mg/dl) 8.8 10.5 Phosphorus (mg/dl) 2.5 4.9 Cholesterol (mg/dl) < 200 AST/SGOT (U/L) 15 37 LDH (U/L) 100 190 Alk Phos (U/L) 50-136 Bilirubin, Total (mg/dl) 0 1.0 Protein, Total (gm/dl) 6.4 8.2 Albumin (gm/dl) 3.4 5.0 Globulin (mg/dl) 2.3 3.5 A/G Ratio (ratio) 1.5 2.5 Uric Acid (mg/dl) 2.6 7.2 Osmolality 260-301 Anion Gap (mmol/l) 10 20 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
URINALYSIS COLOR CHARACTER GLUCOSE BILI QUALITY KETONES Normal Range SPECIFIC GRAVITY 1.003 1.022 OCC BLOOD URINE PH URINE 5 9 PROTEIN URINE UROBILINOGEN 0.2 1.0 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
ABG LABS Normal Values Date: PH 7.35-7.45 PacCO2 35-45 mm/hg CO2 SAT 23-30 mm/hg O2 SAT 94-100 % PaO2 80-100mm/Hg HCO3 22-26 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
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
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
Revised 2013 PN Clinical Daily Assessment Packet Page 13