clinical package
- Mobility or Safety
- Elimination
- Oxygenation: Gas Exchange
- Thermoregulation or fluid and electrolytes
- Inflammation/infection
- Tissue Integrity
- Pain
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Date: |
7/19/2019 |
Student name: |
Clinical Site/Unit: |
TCU |
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Clinical Site Instructor: |
Clinical Site Mentor: |
George |
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Overweight/underweight: |
Allergies: |
No known |
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Marital Status: |
divorce |
Religion: |
lutheran |
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Cultural Background: |
white |
Primary Language: |
English |
Code status: |
1 |
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Diet/Nutrition: |
Activity: |
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Treatments: |
IV/Tubes/Ostomies: |
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Interdisciplinary Cares (OT/PT/RT): |
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Dressings/Wounds: (type & location) |
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Oxygen: (delivery method & amount) |
Dialysis: |
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Admitting Medical Diagnosis(s): |
Multiple sclerosis |
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Primary (if different than Admitting) |
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Secondary (Do not include History Of): |
Localize edema |
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Medication Data Sheet
Scheduled Medications that your patient is currently taking.
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Drug Name and Classification |
Expected action & indication for use |
Side Effects/ Adverse Reactions |
Medication/Food Interactions |
Nursing Administration Special Instructions & Assessments |
Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale |
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Metoprolol 25mg |
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MiraLAX |
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Multi vitamins |
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Omega 3 fatty acid 1000mg |
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Aquaphor ointment |
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Vitamin d 500mg |
. |
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Magnesium 400mg |
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Bisacodyl suppository 10mg |
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Camphor menthol lotion |
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Acetaminophen 650mg |
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Daily “Brainsâ€, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.
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Room #:18 |
Diet: |
Ambulation: wheel chair |
IV fluids: |
Allergies:
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Medications |
Treatments |
Nursing care/interventions |
Vital Signs |
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0700 |
Remove hand splint |
Check vital signs Check for constipation |
138/70 |
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0800 |
Calcium Metoprolol Multivitamins Mega 3 |
Apply oitment |
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0900 |
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1000 |
Ensure |
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1100 |
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1200 |
Tizzadine 4mg |
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1300 |
ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.
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Body System |
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Vital Signs and Pain Level: |
138/70 pain level is zero |
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Sensory: |
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