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1. RNSG 2361 Clinical
2014 Lamar State College – Port Arthur Page 1
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LamarStateCollege –Port Arthur
UpwardMobility Program
RNSG 2361 Clinical
Case Study
Student: Date: Instructor:
Submit Clinical Case Study in RNSG 2361Module 8 assignment area.
Objectives to be met
2 1 0 Points
Earned
Patient’s initials, age and identifiers
appropriate to HIPAA
Information violates HIPAA
Appropriate medical terms and/or
abbreviations used throughout
1-2 Inappropriate medical terms and/or
abbreviations used
>2 Inappropriate medical terms
and/or abbreviations used
Source is documented Source is not indicated in 1 instance Source is not indicated in >1
instances
APA format is correctly used throughout
case study
APA format is incorrectly used in 1-2
instances
APA format is incorrectly used in >2
instances
4-3 <3-2 <2-0 Points
Earned
In-depth present medical history complete Present medical history missing
significant details
Present medical history not included

2. RNSG 2361 Clinical
2014 Lamar State College – Port Arthur Page 2
In-depth past medical-health history
complete
Past medical-health history missing
significant details
Past medical-health history not
included
Cognition, Perception, Communication,
Interaction complete
Cognition, Perception, Communication,
Interaction missing one assessment
criteria
Cognition, Perception,
Communication, Interaction missing
> one assessment criteria
Activity, Exercise complete Activity, Exercise missing one
assessment criteria
Activity, Exercise missing > one
assessment criteria
Nutrition, Elimination, Metabolic complete Nutrition, Elimination, Metabolic missing
one assessment criteria
Nutrition, Elimination, Metabolic
missing > one assessment criteria
Comfort, Function complete Comfort, Function missing one
assessment criteria
Comfort, Function missing > one
assessment criteria

3. RNSG 2361 Clinical
2014 Lamar State College – Port Arthur Page 3
4-3 <3-2 <2-0 Points
Earned
Reproduction,Sexuality complete Reproduction, Sexuality missing one
assessment criteria
Reproduction, Sexuality missing >
one assessment criteria
PsychosocialHistory complete PsychosocialHistory missing one
assessment criteria
PsychosocialHistory missing > one
assessment criteria
Cultural Assessment complete Cultural Assessment missing one
assessment criteria
Cultural Assessment missing > one
assessment criteria
Discharge Information complete Discharge Information missing one
assessment criteria
Discharge Information missing > one
assessment criteria
Nurses Notes complete with appropriate
opening entry, a well written entry at least
every 2 hours, and an appropriate closing
entry; each entry properly signed
Nurses Notes missing appropriate
information in one of the following:
opening entry, a well written entry at
least every 2 hours, and an appropriate
closing entry; each entry properly
signed
Nurses Notes missing appropriate
information in >1 of the following:
opening entry, a well written entry at
least every 2 hours, and an
appropriate closing entry; each entry
properly signed
Primary & Secondary Diagnoses
pathophysiology, treatments, medical
interventions, and nursing assessment
properly discussed
Incomplete information in one area:
Primary & Secondary Diagnoses:
pathophysiology, treatments, medical
interventions, and nursing assessment
Incomplete information in>1 area:
Primary & Secondary Diagnoses:
pathophysiology, treatments, medical
interventions, and nursing
assessment
Medications listed correctly with generic &
brand name; dosage, route, frequency,
indications for patient, significant adverse
reactions, and appropriate nursing
interventions
Incomplete information in one area:
Medications listed correctly with generic
& brand name; dosage, route,
frequency, indications for patient,
significant adverse reactions, and
appropriate nursing interventions
Incomplete information in >1 area:
Medications listed correctly with
generic & brand name; dosage,
route, frequency, indications for
patient, significant adverse reactions,
and appropriate nursing
interventions
Lab Studies correctly identifies lab tests,
normal values, admission & most recent
patient values indicating H, L, N,
significance to this patient, and nursing
responsibilities
Incomplete information in one area:
Lab Studies correctly identifies lab
tests, normal values, admission & most
recent patient values indicating H, L, N,
significance to this patient, and nursing
responsibilities
Incomplete information in >1 area:
Lab Studies correctly identifies lab
tests, normal values, admission &
most recent patient values indicating
H, L, N, significance to this patient,
and nursing responsibilities
Diagnostic Exams identified with results in
student’s word, nursing responsibilities
and implications for patient
Incomplete information in one
area:Diagnostic Exams identified with
results in student’s word, nursing
responsibilities and implications for
patient
Incomplete information in >1 area:
Diagnostic Exams identified with
results in student’s word, nursing
responsibilities and implications for
patient
Minimum of5 appropriate NANDA problems
identified, properly written, and properly
prioritized with Top 3 nursing diagnoses
further developed
One error in: Minimum of 5 appropriate
NANDA problems identified, properly
written, and properly prioritized or only
2 nursing diagnoses further developed
>1 error in: Minimum of 5
appropriate NANDA problems
identified, properly written, and
properly prioritized or only 1 nursing
diagnoses further developed
Subjective & objective data included that
are defining characteristics of nursing
diagnosis
Either Subjective or Objective data are
missing on one or more of care plans
Both subjective & objective data are
missing on one or more of care plans

4. RNSG 2361 Clinical
2014 Lamar State College – Port Arthur Page 4
4-3 <3-2 <2-0 Points
Earned
Well written Goals which include:
Appropriate short term and long term goals;
outcomes that are: specific, realistic &
measurable, a definite time frame for
achievement, and consideration ofpatient’s
desires & resources
Goals include all but one of criteria:
appropriate short term and long term
goals; specific, realistic & measurable, a
definite time frame for achievement,
and consideration ofpatient’s desires &
resources
Goals missing >1 of criteria:
appropriate short term and long term
goals; specific, realistic &
measurable, a definite time frame for
achievement, and consideration
ofpatient’s desires & resources
Interventions:relate to the goals; are
specific and clearly stated to include: Who
performs,how,when,where,
time/frequency,& amount;include a
rationale, source & page number; and are
indicated as (I) Independent or (C)
collaborative
Interventions include all but one of
criteria: relate to the goals; are specific
and clearly stated to include: Who
performs,how,when,where,
time/frequency,& amount;include
a rationale, source & page number
Interventions missing >1 of criteria:
relate to the goals; are specific and
clearly stated to include: Who
performs,how,when,where,
time/frequency,& amount;
include a rationale, source & page
number
Interventions are properly labeled as (I)
Independent or (C) collaborative
One intervention is not labeled as (I)
Independent or (C) collaborative or one
intervention is incorrectly labeled
>1 intervention is not labeled as (I)
Independent or (C) collaborative or
>1 interventions is incorrectly
labeled
Appropriate evaluations are included for
short term and long term goals
Inappropriate or incomplete
evaluationsfor 1-2 short term orlong
term goals is present
Inappropriate or incomplete
evaluationsfor >2 short term orlong
term goals is present
Clinical Log is appropriately completed with
all areas offering substantialinformation
Clinical Log is completed with one area
offeringless than substantialinformation
Clinical Log is not complete or >1
area offersless than substantial
information
Correct spelling and grammar used
throughout
1-2 errors in spelling and/or grammar >2 errors in spelling and/or grammar
Late Penalty:
25 points up to 24 hours
Greater than 24 hours will result in a zero
for the assignment
Comments: Total Points Earned (maximum
of 100)
Late Points Deduction
Failure to submit electronically
as an attachmentin proper
format (MS Office Word) with
grading rubric as first page of
document
Points deduction (maximum of
10 points)
Final Score

5. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 5
Patient Information
Patient
Initials:
Age: Admissi
on Date:
Date of
Care:
Room:
Medical Diagnoses:
Information obtained
from:
Patient Spouse Other
Can you speak English? Yes No
Can you read English? Yes No
Are you able to read lips? Yes No
Native Language?
Do you speak or read any other language?
History of Present Illness
(Include date of onset, initial signs and symptoms, course of illness from onset to present and current status of
illness):
Past medical health history:
Allergies:
Cognition/Perception/Communication/Interaction
Level of Consciousness:
Alert Lethargic Semicomatose Stuporous Comatose
Describe Variance:

6. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 6
Behavior: Appropriate to Situation
Combative Confused Anxious Restless Flat Affect
Uncooperative Withdrawn Other
Describe Variance:
Oriented to:
Person Place Time
Describe Variance:
Thought Content: Appropriate to Situation
Delusions Obsessions Somatic Concerns Depersonalization
Compulsions Paranoia/Suspiciousness Hallucinations
Describe Variance:
Thought Process:
Logical Sequential Relevant Goal Directed Follows Commands
Disjointed Irrelevant Tangential Circumstantial
Describe Variance:
Memory:
Short-term Memory Intact Long-term Memory Intact
Uncooperative Memory Not Intact
Describe Variance:

7. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 7
Speech:
Clear Slurred Stutter Difficult to Understand
Laryngectomy Other
Aphasia Type:
Describe Variance:
Pupil Reaction: PERRLA
Right: Left:
Size (highlight) 1 2 3 4 5 mm Size (highlight) 1 2 3 4 5 mm
Brisk Sluggish Brisk Sluggish
NR NR
Other Other
Describe Variance:
Eyesight:
Normal Nearsighted (Myopia) Farsighted (Presbyopia)
Wears Glasses Contacts Blurred Diplopia Glaucoma
Blind: OD OS
Describe Variance:
Hearing: Normal
Hard of Hearing (Presbycusis): Left Ear Right Ear
Uses Hearing Aid: Left Ear Right Ear
Deaf: Left Ear Right Ear
Neurological:

8. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 8
Normal Motor Disturbances Seizures Tremors
Headaches Numbness Tingling
Other:
Describe Variance:
Glasgow Coma Scale (GCS)
Activity Score Patient Score
EYE OPENING
Spontaneous
To sound
To pain
None
Eyes open, not necessarily aware = 4
Non-specific response, not necessarily to command = 3
Pain from sternum/limb/supra-orbital pressure = 2
Even to supra-orbital pressure = 1
MOTOR RESPONSE
Obeys commands
Localizes pain
Normal flexion
(Withdrawal)
Abnormal flexion
Extension
None
Follows simple commands = 6
Arm attempts to remove supra-orbital/chest pressure = 5
Arm withdraws to pain, shoulder abducts = 4
Withdrawal response or assumption of hemiplegic posture
= 3
Shoulder adducted and shoulder and forearm internally
rotated = 2
To any pain; limbs remain flaccid = 1
VERBAL RESPONSE
Oriented
Confused
Inappropriate
Incomprehensible
None
Converses and oriented = 5
Converses but confused, disoriented = 4
Intelligible, no sustained sentences = 3
Moans/groans, no speech= 2
No verbalization of any type = 1
Patient Total Score

9. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 9
Activity/Exercise
Respiratory:
No Cough Cough Non-productive Productive
Describe (color, characteristics, amount):
Dyspnea: At Rest With Exertion Orthopnea:# of pillows used:
Requires HOB increase 
Tachypnea Pursed lip
Breathing Pattern:
Non-labored Labored Symmetrical Asymmetrical Periods of Apnea
Describe Variance:
Oxygen delivery
mode:
Room Air NC Mask (type)
Trach collar Other
Pulse Oximetry on: On Room Air % (result)O2 type of delivery mode % (result)
Breath Sounds: Clear/Equal Bilaterally
R L Location
Crackles
Rhonchi
Wheezes
Diminished
Absent
Describe Variance:
Tracheostomy: NA Size: Type:
Describe Secretions (color, characteristics, amount):
Frequency of Suctioning:

10. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 10
Chest Tube: NA Location:
Water Seal Suction (amount):
Drainage (color, characteristics, amount):
Pulse Rate: Apical Radial Pulse Deficit
Describe Variance:
Heart Rhythm:
Regular Irregular Describe:
Chest Pain Palpitation
Heart Sounds:
Audible S1S2 Murmur Extra Sounds
Describe Variance:
EKG Rhythm: (per chart) None in chart, none performed
Pacemaker Type:
Describe Variance:
Pulses: (A) Absent (W) Weak (S) Strong (D) Doppler
Carotid: Right Left
Brachial: Right Left
Radial: Right Left
Femoral: Right Left
Popliteal: Right Left

11. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 11
Post Tibial: Right Left
Dorsal Pedis: Right Left
JVD Describe Variance:
Capillary Refill:(# of seconds)
UR UL
LR LL
Extremities:Color: WNL for patient or describe
UR UL
LR LL
Temperature H (hot) W (warm) C (cool/cold)
UR UL
LR LL
Calf tenderness: Right Left
Describe color change with positional changes:
Edema:
None Generalized (Anasarca) Ascites Dependent
Non-pitting Pitting
Scale: +1 (2mm) +2 (4mm) +3 (6mm) +4 (8mm)
Location:
Activities of Daily Living:Identify as(I) Independent(A) Assist(D) Dependent
Feeding Bathing Grooming Toileting Dressing
Other

12. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 12
Describe Variance:
Mobility: Ambulatory Ambulatory w/ assistance
Transfer w/ assistance Bed to Chair Bed rest
Other
Activity Tolerance: No Problem
Weakness Fatigue Dizziness Light-headed DOE
Describe Variance:
SCD's TED's Other
Fall Risk Assessment
Check all applicable items and add scores.
Age
(1) 0-3 years
(1) 65-79 years
(2) 80+ years
History of Fall
(0) No Falls
(2) Recent 1-2 Falls
(4) Fall this hospitalization or is
reason admitted
Misc
(3) Post-op Less 48hrs
(5) Needs Constant Supervision
Mental Status
(0) Oriented / Comatose
(2) Confused / Abusive
(4) Intermittent Confusion
(3) In Denial Illness / Deficit
(4) Agitated / Violent and/or
Disoriented / Impulsive
Elimination
(0) Independent / Continent
(1) Catheter
(2) Frequency / Nocturia
(4) Needs Assistance
(5) Independent and incontinent
Communication
(0) English
(1) Non English
(2) Aphasia / Short term memory
loss
Meds/Drugs
(3) Antihypertensives
(2) Diuretics
(2) Laxatives / GI Meds
(3) Sedatives / Narcotics /
Alcohol
Physical Impairment
(1) Cane / Walker
(2) Visual / Perceptual
Impairment
(1) Hearing Loss
(2) Orthostatic
Hypotension / Dehydration
(3) Vertigo / Dizziness
(3) Confined to bed, chair,
restraints
(3) Paralysis / Needs Assistance
(4) Seizure disorder
Plan For Prevention Safety Levels

13. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 13
(Select All That Apply)
Safety Check
Protocol
Restraints
Bed Alarm
Protective Devices
Floor Mats
Level I0-6points
Level II7-14 points
Level III15+points
Patient Fall Risk Score
Identify and discuss in-depth safety concerns for your patient.
Safety Concerns:
Nutrition/Elimination/Metabolic
Height: / (in/cm)
Include both
Weight: / (lbs/kg)
Include both
Ideal Body Weight: /
(lbs/kg) Include both
General
Appearance:
Well-nourished
Obese Thin Cachectic Other
Describe Variance:
Recent Weight: No Change
Loss Gain IntentionalHow
much? (lbs/kg)
Over what amount of time?
Describe Variance:
Mouth: Full Dentition
Loose Teeth Missing some teeth Edentulous Dentures: Upper
Lower Partial Lesions Sore Mouth
Describe Variance:

14. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 14
Gums: Moist Pink Dry
Pale Hyperplasia Other:
Describe Variance:
Tongue: Moist Pink Dry
Coated Other
Describe Variance:
Mucous
Membranes:
Moist Pink Dry
Pale Other
Describe Variance:
Type of Diet: % Eaten:
Fluid Restriction: cc's
Recent changes in: Appetite Eating Describe variance:
Indigestion Nausea Vomiting Anorexia Choking with solids
Choking with liquids
DifficultyChewing DifficultySwallowing
Describe variance:
NG G-tube J-tube G/J-tube Small feeding tube
Tube feeding Bolus Continuous
Formula (type & strength): Rate:
TPN: Central Peripheral
Rationale for Diet:
Abdomen: Soft Non-tender Flat Round
Distended Gravid Firm Rigid Cramps

15. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 15
Pain Masses Gas
Describe Variance:
NG LIS LCS
Drainage (color, characteristics, amount):
Bowel Sounds: X 4 Quads Normal
Hyperactive Hypoactive Absent
Describe Variance:
Stool: Continent Incontinent Hemorrhoids Blood in stool
Ostomies: Colostomy Ileostomy Other
Last BM: Usual Pattern:
Describe stool or ask patient to describe (color, characteristic, amount, frequency):
Stoma: Describe (color, size):
Skin: Intact Other
Describe Variance:
Bladder: Continent
Incontinent Frequency Urgency Retention Dribbling
Burning Dysuria Anuria Nocturia Distention
Other
Describe Variance:
Urine: Clear Dark Cloudy Bloody
Concentrated Odorous Other

16. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 16
Describe urine or ask patient to describe (color, characteristics):
Condom catheter Foley catheter I/O Catheter How often?
Suprapubic catheter Urostomy Nephrostomy tube CBI
Describe Variance:
24 hour I & O: I O (cc)
Dialysis AccessLocation and type:
Comfort/Function
Vital Signs:
Temperature: (site ) Respirations:
B/P: Left arm Right arm Other
Lie: Sit: Stand:
Pulse: Left arm Right arm Other
Lie: Sit: Stand:
Sclera: White
Jaundiced Red Other
Describe Variance:
Skin: Intact Color appropriate
to patient
Warm Dry
Pale Flushed Clammy Diaphoretic Cyanotic
Jaundiced Dusky Mottled Hot Cool/Cold
Other
Describe Variance:
Turgor: Elastic Tenting
Describe Variance:
Rash Scar Wound/Ulcer Lesion Petechiae

17. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 17
Ecchymosis Hematoma Incision(s) Other
Location Description
For incision(s):
Edges well approximated Open Inflammation Redness
Drainage Sutures Staples Other
Describe Variance:
Drain(s)Type:
Drainage of wounds and drains:
Site Amount Color Characteristics Location Type
Dressings:
Site Location Type Condition

18. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 18
Braden Scale
Maximum score 23 = little or no risk
If Braden score is 15-18 = at risk
If Braden score is 13-14 = moderate risk
If Braden score is 10-12 = high risk
If Braden score is 9 or below= very high risk
Clinical Condition Parameters
1.Sensory Perception: Response to Pressure-Related Discomfort
Completely limited (Unresponsive, quad, coma) 1
Very limited (Responds only to painful stimuli, paraplegic, semi-coma) 2
Slightly limited (Responds with some sensory impairment, CVA) 3
No impairment (No limiting sensory deficit) 4
2.Moisture: Degree to Which Skin Is Exposed to Moisture
Constantly moist (always incontinent, two or more linen changes every eight hours) 1
Moist (often incontinent, linen change every eight hours) 2
Occasionally moist (Seldom incontinent, linen changes two every 24 hours) 3
Rarely moist (Skin is dry, routine linen change) 4
3.Activity: Degree of Physical Activity
Bed rest (Confined to bed) 1
Chairfast (Minimum weight bearing, ambulatory w/assist) 2
Walks occasionally (Ambulatory short distance, sits mostly) 3
Walks frequently (Ambulatory outside room, BID) 4
4.Mobility: Ability to Control, Change Body Position
Completely immobile (Cannot move self) 1
Very limited (Makes insignificant movements) 2
Slightly limited (Makes slight changes independently) 3
No limitations (Makes major, independent changes) 4
5.Nutrition: Usual Food Intake Pattern

19. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 19
Very poor (NPO, IV greater than five days, less than 1/3 meals) 1
Probably inadequate (Needs assistance, less than ½ meals) 2
Adequate (TPN, enteral feeding, greater than ½ meals) 3
Excellent (No supplement, eats most meals) 4
6.Friction and Shear: Ability to Maintain Body Position
Problem (Requires complete assist, slides down in bed/chair) 1
Potential problem (Requires maximum assist, sometimes slides down in bed/chair) 2
No apparent problem (Moves independently, maintains good position in bed/chair) 3
Total Score
Discuss patient’s Braden score results including:
Score interpretation:
Contributing factors:
Implications for this patient’s plan of care (include need for pressure reduction device(s) and preferred
type, nutrition, skin care, and any other appropriate measures) Be specific and in-depth:
Parenteral Access: None
#1 Site: IVF (Type) Rate Peripheral lock Location:
Central (Type) PICC Line Peripheral Other
Type of Access (IV Cath size & length):
Without redness, swelling, or pain IV patent Dressing dry and intact
Red Warm Swelling Tender Bleeding
Drainage Other
Describe Variance:

20. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 20
#2 Site: IVF (Type) Rate Peripheral lock Location:
Central (Type) PICC Line Peripheral Other
Type of Access (IV Cath size & length):
Without redness, swelling, or pain IV patent Dressing dry and intact
Red Warm Swelling Tender Bleeding
Drainage Other
Describe Variance:
Epidural Access: None
InfusionMedication: Rate:
Posture: Straight/Erect
Kyphosis Scoliosis Lordosis Other
Describe Variance:
Gait: Steady
Unsteady
Describe Variance:
Assistive Devices: None Cane
Crutches Prosthesis Wheelchair Other
Describe Variance:
Joints: Full mobility per active ROM Full ROM per passive ROM
Limited mobility Contractures Limited ROM Pain

21. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 21
Swelling Tenderness Stiffness Other
Describe Variance:
Muscles: Symmetry Weakness
Flaccid Cramping Spasms Other
Describe Variance:
Strength: (S) Strong (M) Moderate (W) Weak (A) Absent (E) Equal
RUE LUE Equal Unequal
RLE LLE Equal Unequal
Grips: R L Equal Unequal
Pain: None
Location: Rating (1 to 10):
Description:
Constant Intermittent Aching Burning Cramping Stabbing
Dull Throbbing Heavy Crushing Sharp Other
Describe Variance:
Sleep: # of hours: Rested
Does not feel rested after sleep Difficulty falling asleep Difficulty staying asleep Naps
Usual Sleep Pattern:
Other
Describe Variance:

22. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 22
Reproduction/Sexuality
Gender:
Female
Completes self-breast
exam:
Yes No Last mammogram:
LMP: Post-menopausal
Birth Control method:
Last Pap Smear:
G P A Gyn Surgery:
Gyn Problems:
Describe Variance:
Male
Circumcised: Yes No Completes self-testicular exam: Yes No
Describe Variance:
Psychosocial History
What is causing the most difficulty or stress in
your life?
How do you deal with this?
Do you have friends or relatives that you can
call on for help?
Are you very involved in a religious or social
group?
Do you feel that God (or a higher power)
provides a strong source of support in your life?
Are there any spiritual/religious practices that
need to be followed while you are hospitalized?
No Yes
If “yes,” What are they?
Do you use tobacco? No Yes
If “yes,” What type? How often?

23. RNSG 2361
Clinical
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How long in use? How long have you been tobacco free?
Do you use alcohol? No Yes
If “yes,” What type? How often?
How long in use? How long have you been alcohol free?
Do you take any drugs, herbs, or supplements
that are not prescribed?
No Yes
If “Yes,” please explain:
Stage of Development (Erickson) AEB (Identify stage of development, indicate which stage your patient is in,
and provided supporting evidence):
Cultural Assessment
Country of birth? Years in this country
(If an immigrant or a refugee, how long has the patient lived in this country? -You are not questioning legal
status.)
What setting did you grow up in? urban suburban rural
What is your ethnic identity (i.e., Italian-American,
Jewish, Texan, Vietnamese)?
Who are your major support people? family members friends other
Who are the dominant family members?
Who makes major decisions for the family?
Occupation in native country
Present Occupation
Education?

24. RNSG 2361
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Discharge Information
Who do you live with?
Number of children at home and ages:
Who will take care of you after discharge?
Who will provide transportation upon discharge?
Where will you go at discharge?
Home Home w/Home Health - Name of Agency
Nursing Home - Name of Nursing Home
Other
Medical equipment used at home? No Yes
If “yes,” What type?
Does patient use specialty bed? No Yes
If “yes,” What type?
Anticipated needs at discharge:
Equipment (explain):
Supplies (explain):
Transportation (explain):
Safety Concerns: (explain):

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Clinical
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Nurses’ Notes: Include notes that cover the entire shift(s) you cared for patient

26. RNSG 2361
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Patient’s Primary and Secondary Diagnoses
Definition and Pathophysiology of Primary and Secondary Diagnoses:
Primary Diagnosis:
Secondary Diagnoses:
Common Treatments and Medical Interventions for Primary and Secondary Diagnoses:
Primary Diagnosis:
Secondary Diagnoses:
Focused nursing assessment for Primary and Secondary Diagnosesto include:
Primary Diagnosis:
Secondary Diagnoses:
Additional information important to patient care:
SOURCES (APA Format):

27. RNSG 2361
Clinical
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Medications and Parental Therapy
Solution Infusing Rate of Infusion Nursing Interventions
Medication
Generic/Trade Name
Dosage Route Freq Indications –
Specific to your
patient
Adverse
Reactions
Nursing
Interventions -
Specific to your
patient
SOURCES (APA Format):

28. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 28
Lab Studies
LAB
STUDY
NORMAL
VALUE
PATIENT VALUE
Indicate if value is:
High, Low, Normal
SIGNIFICANCE
What does the abnormal
value mean to your
specific patient?
NURSING
RESPONSIBILITIES
Identify responsibilities,
specific to your patient,
for all lab studies: Prior to
the lab study and after any
abnormal value
Admission Most
Recent
SOURCES (APA Format):

29. RNSG 2361
Clinical
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Diagnostic Exams related to Patient Assessment
Diagnostic
Exam(s)
Nursing Responsibilities -
Specific to your patient
Results (in your own words) Implications for Patient -
Specific to your patient
SOURCES (APA Format):

30. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 30
Problem List
List and Prioritize a minimum of 5 problems. Problem List may include only one“Risk for” NANDA statement.
Priority # Date Problem in NANDA form Nursing Diagnosis R/T Etiology AEB Subjective
and Objective Data
SOURCES (APA Format):

31. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 31
Diagnosis by Nanda
Type your answers in the space provided. The boxes will expand as you type.
Sources (APA Format):
DIAGNOSIS BY
NANDA
PLAN/GOAL INTERVENTION
(Indicate I or C)
RATIONALE
(Paraphrase
information and
Include Reference
Page #)
EVALUATION
NANDA #1: SHORT TERM
GOAL #1
Patient will
1. 1. 1.
SHORT TERM
GOAL #2
Patient will
2. 2. 2.
AEB
SHORT TERM
GOAL #3
Patient will
3. 3. 3.
Subjective Data:
SHORT TERM
GOAL #4
Patient will
4. 4. 4.
Objective Data: LONG TERM
GOAL#1
Patient will
5. 5. 5.

32. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 32
Type your answers in the space provided. The boxes will expand as you type.
Sources (APA Format):
DIAGNOSIS BY
NANDA
PLAN/GOAL INTERVENTION
(Indicate I or C)
RATIONALE
(Paraphrase
information and
Include Reference
Page #)
EVALUATION
NANDA #2: SHORT TERM
GOAL #1
Patient will
1. 1. 1.
SHORT TERM
GOAL #2
Patient will
2. 2. 2.
AEB
SHORT TERM
GOAL #3
Patient will
3. 3. 3.
Subjective Data:
SHORT TERM
GOAL #4
Patient will
4. 4. 4.
Objective Data: LONG TERM
GOAL#1
Patient will
5. 5. 5.

33. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 33
Type your answersinthe spacesprovided. The boxeswill expandasyoutype.
Sources (APA Format):
DIAGNOSIS BY
NANDA
PLAN/GOAL INTERVENTION
(Indicate I or C)
RATIONALE
(Paraphrase
information and
Include Reference
Page #)
EVALUATION
NANDA #3: SHORT TERM
GOAL #1
Patient will
1. 1. 1.
SHORT TERM
GOAL #2
Patient will
2. 2. 2.
AEB
SHORT TERM
GOAL #3
Patient will
3. 3. 3.
Subjective Data:
SHORT TERM
GOAL #4
Patient will
4. 4. 4.
Objective Data: LONG TERM
GOAL#1
Patient will
5. 5. 5.

34. RNSG 2361
Clinical
2014 Lamar State College – Port Arthur Page 34
Clinical Log
Clinical Site: Student Name:
Date:
Patient Description Current Medical Diagnoses:
Focused Physical Assessment Narrative Statement:
Psychosocial Assessment Narrative Statement:
Student's Learning Learning Gained During This Clinical Experience:
Learning Needs Related To This Clinical Experience:
Problems
Encountered/Alternative
Approaches
Problems Encountered During Clinical/Alternative Approaches:
Student’s
Feelings/Perceptions
Student’s Feelings/Perceptions Following This Clinical Experience:
Rev. 07/29/2014sm