Patient Initials:

Rm #:

Cabrillo College
Clinical Preparation Sheet - Part 1

Student:
Date(s) of Care:

Pathophysiology
On the back of this sheet or a separate paper, describe in writing or by drawing a concept map the pathophysiology of the
chief complaint and the admitting disease process. Include, if you can, how the patient's other chronic illnesses or
conditions PMH (prior medical history) contributes to or affects the primary diagnosis. Compare and contrast your patient
to the textbook description of the clinical manifestations, diagnostic procedures, medical and nursing care.
Date of admission:
Chief complaint:
Age:
Doctors:
Admitting diagnosis:

Allergies:
Diet:

Date and type of surgery:

Activity Order:
Code Status:
lab ordered for date(s) of care :

PMH / Chronic conditions:

IV type & site:

Other disciplines involved in care of client (e.g. respiratory,
physical or occupational therapy, social service, etc.)

IV solution & rate:

Other:

Significant abnormal lab values

Why are they abnormal?

How are they being corrected?

1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________
5. _______________________________________________________________________________________________
6. _______________________________________________________________________________________________

Diagnostic Procedures

Purpose (if unfamiliar to you)

Patient Prep & Post Care

Results

1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
Tubes, lines, drains or treatments

Purpose (if unfamiliar to you)

Nursing assessment/documentation

1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________

8/23/2005

Patient Initials:
Rm #:

Student:
Date(s) of Care:

Clinical Preparation Sheet - Part 2

What teaching will my pt. require? How do I prepare for it? (What

I am going to pay special attention to:

resources are available in the hospital (videos, brochures, etc.)

Time
Management
Report ___

Notes / To Do List / Questions/

Skills to review/ Words to look up
____ - ____

Quick
assessment
Airway
Breathing
Circulation
Intake
Output
Pain
Safety

Areas I was strong in:

8/23/2005

____ - ____

____ - ____

End-of-Shift 9list

Charting
MARs
Signatures
I&Os
Goodbye to pt.
Report to RN
9Pockets
No patient ID on
papers

Resources for Prep: M/S textbook;

Skills book; Lecture notes; Medical Dictionary
Pathophys. Book; N. Dx. Book; Lab/Dx book;
Drug/Pharm Book; Internet; Hospital procedure
manual ; Other:

Post-Clinical Self-evaluation
Areas needing improvement:

Patient Initials:
Rm #:

Student:
Date(s) of Care:

Clinical Work Sheet

Neuman System
Variables
Psychological

Assessment
Date/Time

Ht/Wt

LOC
Wakefulness
Orientation
Speech
Follows commands
Pupils
Swallow

INTAKE
Type
Amt

MUSC-SKELETAL
Extremity Strength
Sensation
ROM
Activity / Gait

Developmental
Developmental stage
Maturational events
Significant life events
Transitions stressors
Role

OUTPUT
Type
Amt

CARDIO
Heart Sounds
Pulses
Edema
Capillary Refill
Jugular Vein Distention

Sociocultural
Access to healthcare
Family resources
Economic status
Family structure
Ethnic-cultural
Language
Literacy

Last BM _________
Dressings & Wound
Care

PULM
O2 amt/mode
O2Saturation
Respiratory effort
Lung Sounds
Cough/Secretions
Chest Tubes

Spiritual
Religious beliefs
Spiritual values
Hopefulness

FSBG

Physiological

Safety Issues
Restraints
Fall precautions

Nausea/vomiting
Tube feeding: type/site
Other tubes/drains
GU
Urine description
Catheter
Time

Time

Insulin

Other Treatments

GI
Abdomen
Bowel Sounds
Appetite / % eaten

(start systems review)

SKIN
Color/Temp/Turgor
Braden score/stage
Hydration
IV site

Time

Assessment
Date/Time

NEURO

Coping methods
Mood/Affect
Cognitive abilities
Attitudes
Values
Memory
Thought content
Hallucinations
Agitation

Vital Signs

Physiological
(Systems Review)

HOH
Poor vision
other

Todays lab results

BP
HR
RR
Temp
Pain
8/23/2005