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Health Professions, Science and Wellness

Question Description

School of Health Professions, Science and Wellness

Department of Nursing

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Please provide as many details about your writing struggle as possible

Academic level of your paper

Type of Paper

When is it due?

How many pages is this assigment?

Daily Clinical log

Spring 2017

Course: __________________________________________________________________________

Student: _________________________________ Date: _____________________________

Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________

Date of Admission: ________________ Date of Care: _____________________________

Present Medical Diagnoses: ____________________________________________________

Present Surgery (if applicable): _____________________ Date of Surgery: ______________

Allergies: __________________________ Code Status: ________________________

Vital Signs T_____________ P_____________ R____________ BP______________ SPO2___________

General Appearance

Psychiatric

HEENT

Neck

Breasts

Lymph Nodes

Pulmonary

Cardiovascular

Skin

Nails

Abdomen

Genitourinary

Pelvic

Rectal

Extremities

Musculoskeletal

Neurological (DTR’s, reflex grading, cranial nerve evaluation)

Incisions

Drains

Diet/Nutrition

IVs

Intake and Output

Fall Risk Assessment (include score)

Pressure Ulcer Risk Assessment (include score)

Pain assessment (include reassessment)

TimeScoreInterventionReassessment TimeScore

Diagnostic Assessments – Important EKGs, X-Rays, and Labs

Lab/Other TestPatient valuesInference

Medications Administered:

MedicationsDose/Brand name/Generic nameIndication of useAdverse Effect/Side effectNursing Implications
Treatments and ProceduresDay & TimesRationale

Nursing Interventions:

Assessment FindingsNursing DiagnosisOutcomeNursing InterventionsEvaluations

Reflections of the day on meeting course objectives:

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