N4810 Clinical Paperwork Rev 11/6/13

California State University, Stanislaus

School of Nursing

N4810 Adult Health Nursing II Clinical

3 units DIRECTIONS FOR COMPLETING THE CLINICAL PLAN OF CARE

The Clinical Preparation Form is considered homework in which the student prepares to give nursing care by first reviewing pertinent aspects of patient care specific to the patient selected during the clinical experience. The worksheet must be completed prior to the beginning of the clinical learning experience. There are a number of sections to this worksheet and each section is to be completed. The following are the directions for completing the worksheet. If you have any questions about completing the worksheet or regarding instructor comments on you work, please contact your clinical instructor as soon as possible. Submit electronically, unless specified otherwise by your clinical instructor. Student/Date: Include your full name and the date of the clinical experience Patient Initials/Medical Record Number/Ethnic or Cultural Background: Do not use the name of the patient, use only the patient's initials and medical record number. Don't forget to include information about your patient's cultural background. Admission Date: Identify the date of admission to the hospital. Admitting Diagnosis: Identify the admitting diagnoses of the patient. Other Diagnosis/Surgical Procedures: Look on the H&P, the admitting note, the nursing history and the operative note. If applicable identify all medical diagnosis and surgical procedures done currently or in the past. Allergies: Note specific allergies. If none, write "none" or NKDA" Diet: Identify the specific diet for patient Intake and Output (I & O): Indicate if the patient is on I & O includes all pts. receiving IV therapy IV: Indicate the type and location of IV, type of solution and the rate per hour. Invasive Tubes: Indicate any invasive tubes that are present. Pertinent Laboratory & Diagnostic Information: Identify the date of the lab work, low or high values accompanied by arrows up or down to demonstrate the trend. Medications: Identify the name of the drug, both generic and trade, mechanism of action, side effects, rationale, and nursing implication and patient teaching. This should be done for every medication the patient is receiving. Use your drug book. Patient Care Plan: Review the pt. care plan for accuracy and thoroughness. Make any changes you feel are appropriate. For example, add a problem which you feel needs to be included. Describe the expected outcome and the appropriate nursing interventions.