CENTRAL CONNECTICUT STATE UNIVERSITY
Nursing 320 Student Name: Lee Arthur
NURSING CARE CLINICAL WORKSHEET Clinical Site: St. Francis (Shadow Health)
(Packet to be completed after clinical experience) Clinical Date: 4/1/2020
Client’s Date of Admission: 4/1/2020
Section I: PERSONAL PROFILE (Interview the client, review/abstract client medical record).
USE TEXTBOOK: Potter/Perry as a reference tool to provide you information regarding data collection & the
nursing process Clinical Learning Objectives 4, 5 &6
Room#: n/a Insurance Coverage not specified
Patient Initials:*** RH Primary Language English
Age:*** 80 Code Status Full
Gender:*** Male Marital Status Widowed
Section II: Functional Health Patterns
Health Promotion/ Health Maintenance: (Bullet medical diagnosis(es) and surgeries the client
has/had. List dates diagnosed or surgery performed). USE TEXTBOOK: Lewis as a
and nursing process of the patient’s past history. Clinical Learning Objectives 4, 7& 9
Month/Year Diagnosed Diagnosis/Surgery Patient History
57 HTN
57 Oste-Arthritis
69 Enlarged Prostate
ADMITTING DIAGNOSIS Clinical Learning Objectives 1 & 2
Admitting
DVT
Diagnosis:
Surgery during this hospitalization n/a
(If applicable):
Date: 3/30/2020
Allergies:
none
ADMITTING DIAGNOSTIC TESTS/STUDIES/PROCEDURES:
, CENTRAL CONNECTICUT STATE UNIVERSITY
Nursing 320 Student Name: Alyssa Aponte
NURSING CARE CLINICAL WORKSHEET Clinical Site: St. Francis (Shadow Health)
(Packet to be completed after clinical experience) Clinical Date: 4/1/2020
Client’s Date of Admission: 4/1/2020
(i.e. X-ray, ECG, bone scan, etc.) USE TEXTBOOK: Lewis, Potter/Perry as a reference tool to provide you
information regarding the reason diagnostic test, study or procedure performed and normal/abnormal results.
Clinical Learning Outcomes 1 & 2
Test/Study/Procedure & Reason ordered for your client. Result
Date Ordered
Nutrition- Metabolic (Route, Type, Tolerance) Discuss clinical observations, laboratory data, diet hx,
height/weight ratio, and psycho-social data. Include current diet, why on this diet, feeding schedule, what foods
to eat/avoid, intake/output). Consult ht/wt graphs in chart. If on calorie count, supplemental feedings, or fluid
restriction, then please state rationale.) USE TEXTBOOK: Lewis, Potter/Perry, and Ackley.
Clinical Learning Objectives 1 & 2
Height: 5’10 Weight: n/a BMI: n/a
Current Diet: Regular diet.
Brief Nutritional History:
PT reports to have a typical American diet: meats and pastas. Tries to eat fruits and veggies. Loves vanilla ice
cream. Not hungry lately.
Health Promotion: oral health, sun protection (Clinical Learning Objectives 3, 6, 7, 8 & 9)
Physical exam of skin to include the following data: turgor, color, lesions (if any), rash (if any), nails, hair,
wound assessment (if appropriate), IV site assessment (if appropriate), skin temperature, quality of mucous
membranes, dentition
• Turgor: tenting
• Color: no abnormal finding
• Lesions (if any): n/a
• Rash (if any): n/a
• Nails: maintained
• Hair: hair but has reciding hair line, clean, well-groomed.
• Wound assessment (if appropriate):
• IV site assessment (if appropriate):
• Skin temperature: n/a
• Quality of mucous membranes: n/a
• Dentition: PT reports that he has his teeth.
Nursing 320 Student Name: Lee Arthur
NURSING CARE CLINICAL WORKSHEET Clinical Site: St. Francis (Shadow Health)
(Packet to be completed after clinical experience) Clinical Date: 4/1/2020
Client’s Date of Admission: 4/1/2020
Section I: PERSONAL PROFILE (Interview the client, review/abstract client medical record).
USE TEXTBOOK: Potter/Perry as a reference tool to provide you information regarding data collection & the
nursing process Clinical Learning Objectives 4, 5 &6
Room#: n/a Insurance Coverage not specified
Patient Initials:*** RH Primary Language English
Age:*** 80 Code Status Full
Gender:*** Male Marital Status Widowed
Section II: Functional Health Patterns
Health Promotion/ Health Maintenance: (Bullet medical diagnosis(es) and surgeries the client
has/had. List dates diagnosed or surgery performed). USE TEXTBOOK: Lewis as a
and nursing process of the patient’s past history. Clinical Learning Objectives 4, 7& 9
Month/Year Diagnosed Diagnosis/Surgery Patient History
57 HTN
57 Oste-Arthritis
69 Enlarged Prostate
ADMITTING DIAGNOSIS Clinical Learning Objectives 1 & 2
Admitting
DVT
Diagnosis:
Surgery during this hospitalization n/a
(If applicable):
Date: 3/30/2020
Allergies:
none
ADMITTING DIAGNOSTIC TESTS/STUDIES/PROCEDURES:
, CENTRAL CONNECTICUT STATE UNIVERSITY
Nursing 320 Student Name: Alyssa Aponte
NURSING CARE CLINICAL WORKSHEET Clinical Site: St. Francis (Shadow Health)
(Packet to be completed after clinical experience) Clinical Date: 4/1/2020
Client’s Date of Admission: 4/1/2020
(i.e. X-ray, ECG, bone scan, etc.) USE TEXTBOOK: Lewis, Potter/Perry as a reference tool to provide you
information regarding the reason diagnostic test, study or procedure performed and normal/abnormal results.
Clinical Learning Outcomes 1 & 2
Test/Study/Procedure & Reason ordered for your client. Result
Date Ordered
Nutrition- Metabolic (Route, Type, Tolerance) Discuss clinical observations, laboratory data, diet hx,
height/weight ratio, and psycho-social data. Include current diet, why on this diet, feeding schedule, what foods
to eat/avoid, intake/output). Consult ht/wt graphs in chart. If on calorie count, supplemental feedings, or fluid
restriction, then please state rationale.) USE TEXTBOOK: Lewis, Potter/Perry, and Ackley.
Clinical Learning Objectives 1 & 2
Height: 5’10 Weight: n/a BMI: n/a
Current Diet: Regular diet.
Brief Nutritional History:
PT reports to have a typical American diet: meats and pastas. Tries to eat fruits and veggies. Loves vanilla ice
cream. Not hungry lately.
Health Promotion: oral health, sun protection (Clinical Learning Objectives 3, 6, 7, 8 & 9)
Physical exam of skin to include the following data: turgor, color, lesions (if any), rash (if any), nails, hair,
wound assessment (if appropriate), IV site assessment (if appropriate), skin temperature, quality of mucous
membranes, dentition
• Turgor: tenting
• Color: no abnormal finding
• Lesions (if any): n/a
• Rash (if any): n/a
• Nails: maintained
• Hair: hair but has reciding hair line, clean, well-groomed.
• Wound assessment (if appropriate):
• IV site assessment (if appropriate):
• Skin temperature: n/a
• Quality of mucous membranes: n/a
• Dentition: PT reports that he has his teeth.
