Wilkes-Barre Area Vocational-Technical School

WILKES-BARRE AREA VOCATIONAL-TECHNICAL SCHOOL

PRACTICAL NURSING PROGRAM

CLINICAL ASSIGNMENT SHEET (Instruction Version)

Student’s Name: ______Date: ______

Patient’s Initials: ______Room Number: ______Age: ______Sex: ______

Allergies: ______Diet: ______Activity: ______

Code Level: ______Religious/Cultural Variations: ______

Admission: Height: ______Weight: ______

Primary Diagnosis: (Utilize a reliable, reputable source!!)

Pathophysiology:

·  Describe the disease state and how it affects the normal body functioning

o  Information MUST be obtained from a text or other reliable source

·  Etiology (cause) may be included if desired by instructor

·  Signs and symptoms may be included if desired by instructor

Nursing Interventions (A list of references is required):

·  Interventions must relate to the primary diagnosis

·  Interventions must be obtained from a text or other reliable source

·  Do not include patient specific information/interventions (this is to be included on last page)

·  Interventions must be what the NURSE can perform while caring for the patient

o  Be sure to include:

§  specific patient assessment in relation to the primary diagnosis

§  usual diagnostic tests that may be ordered by the physician

§  usual procedures for the primary diagnosis

o  DO NOT include non-nursing duties

§  NURSING referral to another health care professional is acceptable

Medical/Surgical History:

·  Include patient history pertinent to the primary diagnosis as well as any other significant history

·  Student must possess knowledge of relationship of medical/surgical history to primary diagnosis

Social History:

·  Include information related to

o  Family relationships – who can help with health care needs if needed

§  Would a social service consult be necessary?

o  Habits (good or bad) that affect health (i.e., smoking, ETOH, recreational drugs, exercise, etc.)

Laboratory Values:

Patient Result Normal Value

CBC:
WBC
RBC
Hgb. /
Hct.
Platelet Count
Coagulation Profile:
PT
INR
PTT

Patient Result Normal Value

Chemistry Profile:
FBS
BUN
Cr
Na
K
C1
C02

Chest X-Ray: (Most Recent)

·  List impression

EKG:

·  List interpretation

Any other diagnostic data relevant to your patient’s problem (i.e., Stress Test – Angina)

·  List results

IVs:

·  List type of intravenous access

·  List all intravenous solutions your patient is receiving while you are providing care

o  DO NOT include meds by the IV route (include these on last page under “Medications”)

o  Level III & IV – include rationale for specific IV solution/s

·  Include rate of infusion/s

·  Include site/s

Research all current patient medications on 3x5 cards. On this sheet, list all patient medications and the rationale for your patient taking the medication. Do NOT rewrite med cards.

Medication
·  List ALL medications your patient is receiving
·  Include PRNs / Rationale
·  Briefly list why YOUR patient is receiving drug
o  Keeping in mind – drugs have many different therapeutic actions
·  Example:
o  Patient is on the beta-blocker Inderal
o  Your patient does not have c/v history
o  Why is your patient on this drug?
o  You look it up and discover it can be used for migraine prophylaxis
o  Your patient has hx of migraines
§  This is the rationale

List all your patients’ treatments/diet/care/activity etc. from the Kardex and the rationale for each.

Patient Specific Interventions
·  All information is obtained from Kardex and is patient specific
o  May or may not be related to primary diagnosis
·  List all interventions you will perform while caring for your patient
o  Examples that may be included:
§  ADLs assistance
§  Oxygen therapy
§  Foley catheter
§  Care of wounds (surgical/nonsurgical)
·  Include ancillary department referrals
o  Physical therapy
o  Dietary
o  Cardiac rehab
o  Others / Rationale
·  Discuss why you are performing each intervention