Lakeview College of Nursing
Clinical Preparation Assignment

Name: _______________________________ Date/Week: ____________ Adm. Diagnosis:____________________________Allergies:_____________________
                                                                                                                                                                                                                     (5 pts)

Initials: __________Age: _________    Ht.__________ Wt._________

Birth Calculation:

Gender:   M     F        Ethnicity: ______________________________

Education: ______________________________________________

Where do I live?

I live with__________________________________________________

Do I have any other family? ___________________________________

__________________________________________________________

Admission Info: (why and how did I come to hospital)_______________

_________________________________________________________ 

_________________________________________________________

_________________________________________________________

I have had these procedures while I have been here: ________________

__________________________________________________________

__________________________________________________________

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR      POA      Living Will

Activity Level: ________________________________________

Medical History: ___________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Surgical History: ______________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

What equipment am I using?  (Circle all that apply)

Incentive Spirometer     Foley    NG     IV 

  Cast   Splint    Drain     Telemetry     Oxygen

 Chest Tube    Trach      Ostomy       Dressing

TED/SCS      Walker/Crutches      Wheelchair

Other_______________________________    

I am rating my pain as a  _______

Using this pain scale____________

Location/Description__________________________________________________________________  

  
  LAB DATA    (List all pertinent/current lab/diagnostic values)                                                                                                                     (5 pts)
TEST	NORMS	ON ADM	NOW	TEST	NORMS 	ON ADM	NO W	TEST	NORMS	ON 
ADM	NOW	
WBC				RBC				K				
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils				HGB/ HCT				NA				
PT				PLT				CL				
INR				APTT				CA				
GLUCOSE				A1-C				CO2				
CHOLESTROL				BUN				MG				
TRIGLYCERIDE				CREATININE				TSH				
HDL/LDL
				BNP				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:                                                     Other:                                                                         Other:
     
     EKG:                                                                Other:                                                                         Other:
	
CORRELATION: How does each abnormal test or lab relate to the diagnosis:                                                                                          

	

Pathophysiology:  Review all data collected and describe what is happening at the cellular, organ, & system level, may use admitting or secondary diagnosis depending on Instructor preference.		(5 pts)		

 MEDICATIONS:                                                                                                                                                              (5 pts)                     

List all medications ordered for your patient. Complete first four columns prior to clinical; last column MUST be completed at end of clinical session.

Name, dose & frequency of administration for this patient. Calculate safe range for each med with child’s weight.	Classification & mechanism of action. [Use your drug guide!]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations with this medication. 
(List 3-5)	 Evaluate medication effectiveness for THIS patient (patient response).Even if you didn’t give it.	

					
                                                                                                                                                                                
PHYSICAL ASSESSMENT DATA      (COLLECT OWN DATA)  DAY 1&2    5 points per day                                ( 10 pts)
Vital Signs:
Pulse Ox %:	BP:	Pulse:

Rhythm:	Respirations:
Rate:
Depth:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    
Characteristics:          	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N

Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________
Cardiac Monitor______________________

RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character
Apnea & RR Monitor__________________	

	
GASTROINTESTINAL:
Diet at home :                 Current Diet:   

Height:                           Weight:

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________
		
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________		
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            

	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________

	
PSYCHOSOCIAL/CULTURAL:
Coping methods,          Educational level
Developmental level (List one G/D level),       Ethnicity, 
Religion & what it means to pt/family
Elements of Play.
Personal/Family Data    (Think about home environment, family structure, and available family support)	

CONCEPT MAP:  Draw a picture or list items in boxes based on your assessment and patient’s history
You must include the following items:  Abnormal Labs, At least one medical dx for patient, psychosocial element, 3 areas noted in the assessment,  play				( 5 pts)

                                                                                         

  Problem List    
     List 5 here                                     ( 1 pts)
                                                    	Nursing Concern/Diagnosis                                                           (    2  pts)
One diagnosis may represent several problems (include R/T for each)	 Priority of  List      (  1   pts )
  Use numbers	

			

1st Priority Nursing Diagnosis:  (1 pts)
																
Nursing Diagnosis________________________________________________________R/T_____________________________________________

AEB____________________________________________________________________________________________________________________

What does the patient/client need to accomplish?
GOALS/OUTCOMES
Nurse or client perspective
List @ least 3 goals
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions  	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response, Status of Goals & Outcomes, Modifications to Plan	

				
	                2    pts                                          2    pts                                                      2    pts                                                    2       pts
Reference(s): List all on back page or attach additional page. Use APA format.    (2 pts)

Lakeview College of Nursing
N308 Spring Semester 2008
Grading Guidelines for Concept Care Map

Patient history from chart & interview (5)						
	Complete
	Used patient’s initials only
	Information clearly presented
Laboratory/Diagnostics (5)								
All normal values listed
	Results of test clearly presented
	Abnormal tests to correlate to diagnosis 	
Pathophysiology (5)									
	Description of cellular, organ, and system level 
Medications (5)									
	Complete
	Safe dosage calculated for individual patient
	Clearly presented
Physical Assessment Data (10)							
	Complete	
Description of each system clearly presented
Systems from chart & interview (5)							
Patient in the center with medical diagnosis, an abnormal 
	findings, medications, and any other pertinent information
	Complete
	Information clearly presented
Problem List, Nursing Diagnosis Prioritized, Nursing Diagnosis (5)		
Nursing Process Care Plan (10)							
	Priority nursing diagnosis 		
		Goals & Expected Outcomes
		Realistic
		Measurable
	Nursing Interventions
		Individualized
		Variety of activities listed
	Scientific rationale
		Accurate
		Pertinent
Sources documented using APA format (written on the back of page 7 of care plan)
	Evaluation							
		Relates to goals, expected outcomes & interventions
		Includes modifications to plan as needed		
									Total:		/50