clinical face sheet form
TRANSCRIPT
CLARKSON COLLEGE DIVISION OF NURSING BACCALAUREATE NURSING PROGRAM CLINICAL FACE SHEET
PATIENT INITIALS: ADMIT DATE: PATIENT AGE: ETHNICITY: CODE STATUS: Code/DNR ADVANCED DIRECTIVES: Living Will/POA
ALLERGIES:
DIET WITH RATIONALE:
ADMISSION/CHIEF COMPLAINT:
PATIENT HISTORY / OTHER MEDICAL DIAGNOSIS:
PATIENT SUPPORT SYSTEM:
CULTURAL/SPIRITUAL PREFERENCES:
CURRENT VITALS:
PRE-LABDATE:
CLINICAL DAY #1 0800 DATE:
CLINICAL DAY #1 1200 DATE:
TPRBP -
ALL CURRENT MEDS (NotPRNs unless receiving frequently): MED DOSE ROUTE TIME INDICATION
IV SOLUTIONS:
PROCEDURES/EQUIPMENT: Activity/Mobility/Assistive Devices NG/PEG/Dobhoff Colostomy/Ileostomy Chest Tube Urinary Drain Wounds Wound Drains Dressing Changes ECG/Telemetry Dialysis Access Neuro Checks O2 - FIO2 SAT Monitor-Oximeter IVs Central Line Saline Lock PICC Mediport ISOLATION TYPE & RATIONALE:
DIABETES/TYPE: INSULIN / ORAL ANTIDIABETICS:
BLOOD GLUCOSE MONITORING:
PATHOPHYSIOLOGY FORM DIRECTIONS:Students may utilize information obtained from a textbook or journal article to thoroughly complete the pathophysiology worksheet each week. Correlate the textbook data to that of your actual client data. Ask: How do my clients signs and symptoms correspond with the textbook diagnosis? The pathophysiology worksheet is available as a template for those students who would prefer to complete it as a computer generated document, you are not limited to the space provided.
Disease: Text Book Data Definition/Etiology: Actual Client Data Onset of Disease:
Signs & Symptoms:
Client Signs & Symptoms:
Diagnostic Tests:
Diagnostic Tests with Results:
Treatments:
Current or Recent Treatments/Medications:
Commonly Used Medications:
Potential Outcomes of Disease Process:
Briefly discuss the impact of the disease process on the clients ability to function:
Reference:
Lab & Diagnosis TestPt. Initials: TestNormal Admit Date
Diagnosis:PreLab Date Clinical #1 Date Clinical #2 Date
Patient Interpretation State Top 3 reasons Why Abnormal
HEMATOLOGY WBC RBC HGB HCT NEUT SEG BAND LYMPH MONO EOS BASO PLT SED RATE 4-11 4-6 12.517 37-50 1-7.7 40-70 0-6 1-3.5 .2-1.1 0-.4 0-.1 150450 0-15Date Date Date Date
COAGULATION PT INR PTT 22.235.5 10.113.3
INR less than 2 w/o anticoagulant 2 -3 with anticoagulant
Test
Normal
Admit Date
PreLab Date
CHEMISTRY NA K CI CO2 CreatinineUrea Nitrogen (BUN)
Clinical #1 Date
Clinical #2 Date
Patient Interpretation
137145 3.6-5 98107 22-30 .7-1.5 9-20 70110 1.62.3 38126 8.410.2 .1-1.3 0-.4 6.38.2 3.5-5 15-4.6 11-66 100250 30170 .3-4 0-1.4 0-1
Glucose Mag Phos Ca Total Bilirubin Direct Bilirubin Total Protein Albumin AST ALT LDH CK CKMB Troponin I C-Reactive Protein
Test Osmolality Amylase Lipase Cholesterol HDL LDL Triglycerides
Normal
Admit
PreLab
Clinical #1
Clinical #2
Patient Interpretation
275305 30110 23300 150200 40110 0-100 0-150Date Date Date Date
BLOOD GASES Arterial pH PCO2 PO2 HCO3 U/A Yello wAmbe r Clear 1.0161.03 5-8 -
ABG Interpretation
Date
Date
Date
Date
Color
Appearance Specific gravity pH Leukocyte Esterase Nitrates Protein Glucose
Test Ketones Bacteria Urobilinogen Bilirubin Casts Crystals RBC WBC
Normal
Admit
PreLab
Clinical #1
Clinical #2
Patient Interpretation
-
2.1 -
0-2 0-2Date Date Date Date
OTHER LABS (C/S) Culture Sensitivity Drug Screen Blood Alcohol Medication Serum Level
DIAGNOSTIC TESTSExam and Date CXR CT Scan INTERPRETATION