Date: ________ Student Name: _______________________ Clinical Site:____________________________________ Clinical Site Instructor:___________________________________ __________________________________________ Room #_405_________Client Initials: ____SR___ ____ Client age: ____52 years_______   Gender: ___Male_______ Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________ Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk) Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________ Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________ Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________ Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________ LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8 Date  Test Normal Value Client Value Significance  7/24 Sodium____135-145_   132 7/25 Hemoglobin 14-18    9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ LABS Look at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8 Lab Test#1: __Sodium 135-145_______________ Systems affects: ______________________________________________ Elevated level: _____________________________________________________________________________ Low level: _132___________________________________________________________________________ Lab Test #2: _Hemoglobin 14-18_________________ Systems affects: ______________________________________________ Elevated level: _____________________________________________________________________________ Low level: 9.4_______________________________________________________________________________ Date: ____________ Client Initials: _SR_____ Student Name: ___________________________­­­­____________________  Medical Diagnosis(s): (found in paper chart) Admitting/Primary: Motor Vehicle Accident ____________________________________   ________________.

1. Date:
________
Student Name:
_______________________
Clinical Site:____________________________________
Clinical Site
Instructor:___________________________________
__________________________________________
Room #_405_________Client Initials:
____SR___ ____
Client age:
____52 years_______
Gender:
___Male_______
Allergies:
Diphenhydramine______________________________
Code Status: ___Full code______________ ________________
Diet/Nutrition:
_________Regular___________________
Activity:
_______________________________
Fall Risk:
Yes / No Yes (High fall risk)
Use of (type/amount/frequency): Alcohol:
___________________
Tobacco (pack years):
________________________

2. Treatments:
_______________________________
IV/Tubes/Ostomies:
______________________________________
Dressings/Wounds: (type & location)
_Shoulder-healing, Back-Tegaderm and clear
absorbent.____________________________________________
______________________
Oxygen: (delivery method & amount)
____N/A___________________________
Dialysis:
______N/A_____________________
LAB RESULTS: (minimum of 2 labs)
Why is this lab significant for this client’s condition? Write
down ABNORMAL lab results and include what the NURSE
needs to monitor for or do related to the abnormal lab result
under the significance column. ONLY USE ABNORMAL LAB
RESULTS QSEN: Informatics, Safety SLO: 3, 8
Date
Test
Normal Value
Client Value
Significance
7/24 Sodium____135-145_ 132
7/25 Hemoglobin 14-18 9.4
_____________________________________________________

3. _____________________________________________________
_____________________________________________________
_____________________________________________________
______________________________
LABS
Look at the 2 labs you looked up for this week. For each of the
labs look up what body system or system(s) it tells you about,
what does an elevated level mean, and what does a low level
mean. Also, are there any special considerations or client
education regarding prepping the client for the test? (example:
fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8
Lab Test#1:
__Sodium 135-145_______________
Systems affects:
______________________________________________
Elevated level:
_____________________________________________________
________________________
Low level:
_132_________________________________________________
__________________________
Lab Test #2:
_Hemoglobin 14-18_________________
Systems affects:
______________________________________________
Elevated level:

4. _____________________________________________________
________________________
Low level:
9.4__________________________________________________
_____________________________
Date:
____________
Client Initials:
_SR_____
Student Name:
___________________________----____________________
Medical Diagnosis(s): (found in paper chart)
Admitting/Primary:
Motor Vehicle Accident
____________________________________
______________________________________
Medical History (includes medical and surgical)
Acute post hemorrhagic anemia
_____________________________________
Alcohol abuse ___________________________________
_____________
PTSD____________________________________

5. Adjustment disorder with other
symptoms___________________________________ ____
Traumatic ischemia of
muscle__________________________________
______________________________________
__________________________________
______________________________________
____________________________________
______________________________________
____________________________________
______________________________________
End of Shift Report or SBAR:
QSEN: Informatics, Team-Work Collaboration SLO: 3
DATE
TIME

6. Date:

7. ____________
Client Initials:
______
Student Name:
_______________________________________----_________
PRN Medication List (
found in paper chart) QSEN: Safety, Evidence Based Practice.
SLO: 2, 4
Medication
(Include dose, time, route, & Frequency)
Classification
Indication for use
OxyCODONE (Immediate release) 5mg tablet-10mg PO
Ibuprofen 400mg tablet PO q6h

10. Medication Data Sheet
Date:
____________
Client Initials:
______
Student Name:
___________________________----_______________________
_
(
Scheduled medications to be given to your client during your
clinical shift)
QSEN: Safety, Evidence Based Practice. SLO: 2, 4
Drug Name, Dose, Route & schedule
Drug Classification, Expected action & indication for use
Side Effects/ Adverse Reactions
(List 3-5)
Medication/Food Interactions
(List 3-5)
Nursing Administration Considerations & Assessments

11. (List 3-5)
Client education & Evaluation of Medication Effectiveness
(List 3-5)
Mirtazapine 7.5mg PO at HS
Nicotine 21mg/24hr Patch Transdermal
Gabapentin 100mg capsule PO

12. Methocarbamol 500mg tablet-1000mg PO
Enoxaparin 40mg/0.4ml injection 40mg subcutaneous
Melatonin 3mg tablet PO at HS
Date:
____________

13. Client Initials:
______
Student Name:
_______________________________________----_________
Patient
________________________ Room:__________
Hallway:_____________
Nurse: ____________________________ NA:
_________________________
Temp
Oral/Tympanic
HR
Regular/ Irregular
BP
Laying/Sitting/Standing Right/left
Resp.

14. O2 %
Room Air/ Oxygen _____L
Pain
Location: Description:
Pain Intervention:
Edema:
Location:__________________ Degree:________________
pitting/non-pitting
Lung sounds:
Right_______________________
Left_________________________
Cough?_____________________
SOB?__________________________

15. Bowel Sounds
_________________________________________
Date of Last BM
______________
Trach:
Times Suctioned
:
Type of Trach suction
:
In-Line
/
Sterile
Vent Settings:
RR
TV
HA
LA
PEEP
Mode

16. LMV
Sensitivity
Insp Time
FiO2
O2
L
Keep O2 above
%
Treatments Done?
Foot care Done?
PATHOPHYSIOLOGY:
For each diagnosis below,
provide a 3-5 sentence
explanation of the pathophysiology of the problem.
(**we count sentences**)
QSEN: Evidence Based Practice, Informatics, Client Centered
Care. SLO: 1, 2, 4
1.
Primary Diagnosis: Open displaced fracture of pelvis
(3-5 sentences)

17. Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
2.
Diagnosis: Alcohol dependence with withdrawal
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
3.
Diagnosis: Closed fracture of multiple ribs of left side
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)

18. 4.
Diagnosis: Closed fracture of transverse process of lumber
vertebra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
5.
Diagnosis: Acute blood loss anemia
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
6.
Diagnosis: Respiratory failure
(3-5 sentences)
Treatments: (3 minimum)

19. Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
7.
Diagnosis: Acute pain due to trauma
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
8.
Diagnosis: Transection of urethra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
Student evaluation of clinical performance:

20. Please describe any procedures/skills you performed/ observed
during the clinical experience. Also, include your assessment of
how well the day went.