Year 2 and 3 CLINICAL WORKSHEET

Section One: CLINICAL PREPARATION

Indicate where information was retrieved from:  Chart  Shift report  Electronic health record and  Clinical
Preparation Materials
Student Name: Date(s) of Care:
Patient Initials: ____________ Room #: __________ Age: Weight: MRP: ___________________
Allergies : _______________________________ Isolation Status : ___________________________________________
Alerts (e.g., AOB) : ________________________ Code Status: ______________________________________________
Date Of Admission: _______________________ Date of Surgery or POD (if applicable): ____________
Expected Discharge Date: __________________

Patient’s Story: (Review ED admission note, ED physician note, admission H&P, most recent progress notes to briefly
describe how the patient became admitted to the hospital).

Reason for Admission: (Admission Diagnoses and/or surgical procedure: include definition, pathophysiology, signs
& symptoms, complications with references (e.g., textbook).

Co-Existing Illnesses: (All pertinent medical conditions the patient lives with but not the main reason for admission
(e.g., diabetes, hypertension). Include all definitions, signs and symptoms, and references.

Orders and Patient Care Needs

(Review provider orders & most recent nursing/interdisciplinary notes)
Diet Order and Feeding Assistance Vital Signs & Oxygenation Needs

Consistency:Regular Minced Pureed Thickened

Fluids
NG/KAO/G-tube (solution, rate, water flushes) Elimination Needs (bowel and bladder including foley)

Hygiene Needs Dressings & Drains

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 IV/Saline Lock/PICC/Central Line (type, solution, rate, insertion Other Orders (including Accuchek with frequency, daily weight etc.)
site)

Safety:  Fall Risk  Restraint  Bed/Chair Mobility Order Ambulate independently 1 Assist
Alarm  Other safety risk:
2 Assist Dependent/Mechanical Lift
Assistive Devices:
Shift Task List: (to do list)

Start of shift report  Orders  End of shift report 

HTT  Review of labs  Additional procedures/skills 

AM care Wound care  Repositioning/mobilization 

Meds Patient Identifiers:  Arm Band On Empty foley/drain 

 Allergy Identification
Charting/I&O  Accuchek 

Caregiver/comfort rounds
Precautions sign 
Call bell in reach 
Bed in lowest position 
Side rails ( when in bed)  No
 Yes (#) ___
Restraints (type):

__________________________________________________________________________________________________
Section 2: Holistic Health Assessment (Subjective and Objective Data Collection)
Highlight or circle significant assessment data or those not within normal limits. Don’t forget to include subjective
data.
VITALS
Temp Temp Pulse Respiration
Time o Pulse Respirations BP O2 Sat % O2 Flow
C Route Quality Quality

PAIN
Location O P Q R

S (include pain score & T U A

indicate scale used)

GLUCOMETER READINGS
Time Reading

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PRIORITY & ABNORMAL LABS AND DIAGNOSTIC TESTS
Lab Tests Normal Patient Results Patient Results Patient Results Abnormal Rationale &
(include priority Range & Date & Date & Date Values and/or Significance
and abnormal (check agency (Trend the last week's (Trend the last week's (Trend the last week's
labs) trending indicate for Test (Why
ranges) values) values) values) what potential ordered, and
problem? relevance to patient
care?)

Other Key Findings and Date Rationale of Diagnostic Test

Diagnostic (Why ordered and relevance to your patient?)
Tests

SYSTEMS ASSESSMENT
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 MUSCULOSKELETAL/NEUROVASCULAR
LOC:  Alert  Confused  Drowsy  Stupor/Dazed  Comatose  Lethargic
 Sedated  Aggressiveness  Non-Responsive  GCS: _______/15
Orientation:  Time  Place  Person  Situation Speech:  Clear  Slurred  Aphasic
ROM:  Active  Passive Any limitations to any joints  No  Yes
Describe location/limitation __________________________________________________________________________
Morse Fall Scale Score: _________________
Muscle strength grading on appropriate area (0-5) (e.g., leg, arm, compare to other extremity):
__________________________________________________________________________________________________

Pupil(s):  PERRLA R = 3mm L = 3mm  Brisk  Sluggish  No reaction

Sensory Response to Stimuli:  Normal Sensation  Numbness  Tingling  Burning
Location: ______________________________________________________________
Neurovascular Assessment:  Pain  Sensation  Movement  Pulses  Cap Refill  Temperature
Sleep Pattern:  Not Applicable  Disturbed Rest  Undisturbed Rest
Comments: _______________________________________________________________________________________

RESPIRATORY

Breathing Pattern:  Regular  Laboured  Shallow  Orthopnea  Irregular (describe) ___________

 SOB/SOBOE Describe: ___________________
Accessory Muscle Use:  Yes, specify - _____________ No Chest Expansion:  Symmetrical  Asymmetrical
O2 Use:  Room Air  O2 Flow rate__________  Nasal Prongs  Venturi mask  Trach mask  Bipap
Other: ___________
Airway or Air Entry: Patent Other: _______________________ Sounds: Clear  Present in all lung lobes
 Diminished (location /lobes): _______________
 Fine crackles  Course crackles Location _______________________________
 Wheezes  Rhonchi  Stridor Location _________________________
 On inspiration  On expiration
Air Entry:  Good air entry all lobes  Diminished (location/lobes) ______________________
Cough:  No  Yes " Is it:  Productive  Non-productive
Strength:  Strong  Moderate  Weak  Ineffective
Quality:  Congested  Harsh  Dry  Moist  Barking
Nasal Discharge:  No Yes Quantity:  Small  Moderate  Copious
Quality:  Mucoid  Purulent (colour) _____________  Blood-tinged  Frank blood
Sputum:  No  Yes Quantity:  Small  Moderate  Copious
Quality:  Mucoid  Purulent (colour) _____________  Blood-tinged  Frank blood

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Comments: _______________________________________________________________________________________

CARDIOVASCULAR

Rate: 85  Tachycardia  Bradycardia

Rhythm:  Regular  Irregular 
Force:  Bounding  Weak
Heart Sounds:  S1  S2 Abnormal Sounds:  S3  S4  Murmurs – Location
_____________________
Apical Pulse:  Auscultated  Palpated Rate: _____________  Pulse deficit
Bilateral Capillary Refill:  <3 seconds Other: _________________
Bilateral Peripheral Pulses:  Pedal and Post Tibial (if either not palpable then do popliteal and femoral)  Radial
Peripheral Edema:  None  Yes (locations) Bilateral ankle-feet-
____________________________________________
 Non-Pitting  Pitting: Scale __________  TEDs  SCDs
Edema Scale
1+ Mild pitting, slight indentation, no noticeable swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks swollen
4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Comments: _______________________________________________________________________________________
SKIN & MUCOUS MEMBRANES

Skin Colour:  Within Patient’s Norm  Flushed  Pale  Jaundiced  Ashen  Cyanotic  Mottled
Extremities:  Within Patient’s Norm  Flushed  Pale  Cyanotic  Mottled  Hemosiderin staining
Temperature:  Warm  Cool
Skin Status:  Dry  Moist  Intact  Pressure Areas (location) _________________________________
Braden Scale: _____/23 (<16 = interventions) Skin Turgor: _______________ Hair Distribution: _______________
Oral Membranes:  Moist  Dry Teeth:  Own  Partial Plate  Dentures – Upper Lower
Skin Lesions Present: (location and appearance): _______________________________________________________
Bruising and/or Rashes (location and appearance): ______________________________________________________
IV/SL site assessment:  Normal  infiltration  phlebitis
IV /SL dressing assessment:____________________________

Wound Drainage
DRESSINGS/WOUNDS  Not Applicable to this patient Sanguineous: large amt. of RBC’s (often open wounds)

Location(s): __________________________________________________ Serosanguineous: clear & blood –tinged

__________________________________________________ Serous: thin, watery, clear
Purulent: thicker than serous due to pus (w/ leukocytes)

Wound etiology:  Pressure  Diabetic ulcer  Venous ulcer  Arterial  Surgical  Other _________________
Dressing Status:  Dry and Intact  Shadowing  Saturated  Wound Vac
Wound(s):  Erythema (Stage 1)  Partial Thickness (Stage 2)
 Full Thickness (Stage 3 or 4)  Eschar or (Unstageable/X)
Size (cm): Length __________ Width __________ Depth __________

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 Wound Bed Appearance ______________________________
Peri wound Appearance_______________________
Incision:  Incision not directly visualized at this time
 Staples/Sutures Intact (Count ______)
 Edges Well Approximated  Reddened  Dehiscence
 Location of any separated wound edges (describe) _________________________________________
Drain:  Hemovac OR  JP Wound drainage (colour, quantity, quality of drainage & odour): _____________________
Comments: _______________________________________________________________________________________

GASTROINTESTINAL

Abdominal Appearance:  Flat  Round  Distended Swallowing:  Intact  Impaired

Nausea:  No  Yes
Vomiting:  No  Yes (amount & colour) ______________________________________________________
Bowel Sounds:  Present x 4 quadrants  Absent  Audible in _______  Hypoactive  Hyperactive
Passing Flatus:  Yes  No
Percussion of Abdomen: ____________________________ Palpation of Abdomen: _________________________
Nature of Stool:  Smooth and Soft  Hard  Loose  Watery Date of Last BM: _______________________
Amount of Stool:  Large  Medium  Small  Smearing
Colour of Stool: ___________________________ Unusual / Foul Odour:  Yes  No
Bowel Continence:  Yes  No
 Ostomy/ type ______________Location _____________________Stoma Appearance_____________________

NUTRITION
Intake % of meal consumed: Breakfast ___________ Lunch ______________ Supper _____________
Fluid Intake:  Oral (amount) ____________  IV _____________  NG/ G-tube ________________________
 TPN _________________  Enteral feeding (formula/rate): ___________ Water flushes: __________

Comments: _______________________________________________________________________________________
GENITOURINARY

Voiding Pattern:  Regular  Frequency  Urgency Output: ____________ (true urine)

Voided unknown amount/times:______________________________
Bladder Continence:  Yes  No Bladder Scan:  Yes, volume: ______  No
Urine Colour:  Colourless  Yellow  Straw  Amber  Concentrated  Tea-Coloured
Urine Characteristics:  Clear  Cloudy  Sediment  Clots  Hematuria
Odour (describe): ________________________________________________
Device/Equipment in Use:  Ostomy (type) _________________ Catheter (size and type) _____________________
 CBI (amount in during shift) ___________________
Comments: _______________________________________________________________________________________

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 PSYCHOSOCIAL ASSESSMENT

What considerations (cultural/personal/values) should we include in your care? __________________________________________________________________________________________________

How does the patient identify themselves? (e.g., gender, ethnicity, etc.) ________________________________________

Spiritual Needs (e.g., meditation, prayer): _______________________________________________________________

Family or Visitors Present during Shift (who?): ___________________________________________________________

Family Structure (Who do you live with? Who do you consider part of your family? Do you have close extended family?):

__________________________________________________________________________________________________

Family Functioning Assessment Data (Who makes decisions in your family? What are you daily routines and how are you supported?):
_______________________________________________________________________________________

__________________________________________________________________________________________________

How does this hospitalization impact your family functioning (e.g., roles, responsibilities)? __________________________________________________________________________________________________

__________________________________________________________________________________________________

Is there anything about your care or treatment that you would like us to be aware of or to take into consideration? (Note: To support trauma-informed care, remember all patients may have experienced some form of trauma,
observe for cues and support physical and psychological safety) _____________________________________________________________________________________________

__________________________________________________________________________________________________

Substance Use or Misuse Concerns: ____________________________________________________________________

Identify Coping Strategies - facilitators (positive) and barriers (negative): __________________________________________________________________________________________________

Growth & Development Stage for Pediatric Clients (Erikson/Piaget; Implications for care)-Year 3 only

__________________________________________________________________________________________

__________________________________________________________________________________________________

Comments: ________________________________________________________________________________________

CARE TRANSITIONS

Discharge Destination (from current unit): ____________________________________________________________

Patient Care Needs Before Discharge: ________________________________________________________________

__________________________________________________________________________________________________

Interdisciplinary Care Needs (e.g., consults, follow up appts):  Social Work  PT  OT  Speech  Dietician  CCAC or Discharge Planning Team  Other:
___________________________________________________

Section 3: Clinical Reasoning and Decision Making (Processing of Assessment InformationIn this section, you
will identify important or significant data; actual & potential problems, risks/complications for the patient; and any gaps in data
collection including pending tests, results or missed assessment.
Clinical Reasoning process step - NOTICING: What data is recognized as important or significant (e.g.,
physiological, psychosocial, etc.)? Include ALL Significant Assessment Data (all data you have highlighted or circled
in Section 1 or 2
Assessment of Learning Needs (including Readiness, Facilitators, Barriers, and Environmental Considerations)

Clinical Reasoning process step - INTERPRETING: what is the significance of the relevant data that was noticed?
Patient’s top 3 PRIORITY care needs based on the identified significant assessment data (ensure to consider psychosocial
needs also):
1.

2.

3.

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Priority Diagnostic Statements: Actual, Risk, or Wellness (based on each of the 3 priority care needs above)
Response related to Etiology as evidenced by Defining Characteristics
Patient Etiology Defining Characteristics
Response
1.

2.

3.

Clinical Reasoning process steps - RESPONDING & REFLECTING: determining priorities and plan of care
based on data noticed and interpreted; what is the evaluation?
Take the top 2 priority diagnostic statements and create a nursing care plan following the template below.
Goal Statement Interventions (3 at minimum) Rationale Evaluation – Patient
SMART goal (What actions should the nurse do to help to treat (What is the best evidence to support Progress with
this problem; One must be a teaching the interventions? Cite your sources)
format intervention; Identify whether the intervention evidence
(with date) addresses the cognitive, affective or psychomotor (Was goal Met, Unmet,
domain) Ongoing)
1st diagnostic The nurse will:
statement Short-
term Goal
(within your shift)

The patient will:

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 2nd diagnostic The nurse will:
statement Short-
term Goal
(within your shift)

The patient will:

Discharge or Long- The nurse will:

term Goal (for 1 of
the diagnostic
statements)

The patient will:

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 Medication Administration Worksheet
Submit a med incident report (near miss, discovered or practice): 1. After your med admin days and 2. Any other shift when incidents occur
Med Incident Report Submitted □
Medication Safe Dose Pharmacological Mechanism of Side Effects Nursing Patient Education
With Generic name, Range and Class and Use Action (provide (Most Common and Responsibilities: Pre-
ordered dose, Route explanation Severe) assessment and Post-
frequency, route Why was this including assessment
and if high alert Is patient ordered for your metabolism/ (including precautions,
med that requires order safe? patient? excretion) interactions with
IDC food/meds

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