Clinical Prep Sheet

Patient's Initials: Code Status: Brief Medical History

(Include social, medical, & surgical history. Write in a narrative format)

Student Name:

Age: Doctor:

Admit Date:

Male/Female

Allergies:

Developmental Stage
(How does your patient fit into this Stage/Task?)

Patient Needs
(Physical, spiritual, cultural or psychosocial needs?)

Primary Medical Diagnosis

(Why is the primary medical problem?)

Pathophysiology
(What is happening in the body?) Put in your own words using your textbook as a reference)

Risk Factors (What causes a patient to be at increased risk for this diagnosis? Underline those that your patient has)

Complications
(What are actual or potential complications of this diagnosis)

Signs & Symptoms of the diagnosis

(Underline those that your patient experience)

How is this condition diagnosed?

(Underline the diagnostic tests that your patient underwent for this diagnosis. Describe the nursing considerations specific to the test)

Treatment
(Nursing actions and management. Include possible/ anticipated/ actual)

Other Medical/Surgical Diagnoses or Procedures

(List other priority medical diagnoses that are currently affecting your patient)

What is the relationship between this diagnosis and the primary diagnosis, if any? Describe the anticipated or actual nursing interventions

Medication Name (Include generic and trade) Dose, Frequency, & Route

Classification ex. Beta-blockier, ACE Inhibitor (Include Pharmacologic and Therapeutic classifications if available)

Action of Medication How does the medication work?

Side Effects

Major Nursing Considerations Interactions and/or compatibilities with complementary substances and other medications. Is there any special monitoring required?

Why this patient takes this medication What is going on with your patient that requires them to take this specific med?

Observation During Clinical What have you observed that tells you the med is working properly (Ex. B/P, Wt, Temp, RR, Lung Sounds, pain level etc.)

Lab Values Please use this lab result sheet to record lab data on your patient. Use your critical thinking skills to determine the significance of the lab value. (I have included an example to show you what is expected). Significant Lab Values
Admission Lab Value (Include Date) Example: 7/15: K+ = 2.7 Current Lab Value (Include Date) Normal Lab Value (Indicate normal range) Normal Range: 3.7 5.1

What makes it significant?

(Relate the result to the disease/treatments/medications/symptoms of the patient. What might be causing the abnormal value? How is or will the abnormal value impact the patient healing and/or health? What additional things would you monitor? If current values differ from admit values, indicate what may have caused the results to change) The patients lab value on admission was low due to the use of Lasix at home to treat edema secondary to CHF. The patient was given multiple IV bumps of Potassium to increase his level to normal. The patient also takes digoxin so the dig level must be monitored to avoid toxicity. Patient risk with hypokalemia: potential fatal arrhythmias

7/17: K+ = 4.2

3) Nursing Diagnosis: Problem (Nursing Diagnosis): Etiology (R/T): As Evidenced by (E/B): Outcomes (Measurable and Realistic for your Patient) Nursing Interventions/Rationale (What interventions did you do to resolve the problem and help meet the outcome? What specific activities did you perform in clinical or did you see performed? (minimum of 4 -6 interventions) 1. 2. 3. 4. 5. 6. 2. 1. 2. 3. 4. 5. 6. Evaluation (Is outcome achieved? Does plan need to be revised?)

1.

4) Potential Complication (PC): Identify a potential complication? Why is the patient at risk for this complication? What monitoring (interventions) will you perform to detect this potential complication?