COVER SHEET

Name
Week #
Date

CALIFORNIA STATE UNIVERSITY, LOS ANGELES SCHOOL OF NURSING

Student: ___________________

Clinical Instructor: _________________

Date: ______________
N223 CRITERIA AND GRADING FOR NURSING Weekly Clinical Assignment Worksheet
1.

Due date: The Weekly Clinical Assignment Worksheet is due at 7 AM each week.

2.

Late papers are unacceptable. Unless prior arrangements for extenuating

circumstances have been made with the faculty member, late papers will be
penalized as follows: 10% for the 1st day late, and 1% for each day thereafter.

CATEGORIES

Comment

Initial Nursing Assessment: completion, Students

must submit a Student Assignment Work Sheet

Points
5

Patient Data Base: Patient basic conditioning

factors, health status prior to hospitalization,
history of illness, ability of ADL's and life style,
support system, and home medications

2.5

Pathophysiology: signs, symptoms, ancillary

data orders, diagnostic testing orders, clinical
manifestations & current theories of the causes.

2.5

Nursing Care and Medical Treatment,

Referenced nursing care,
Diet,
Medications,
Treatment,
Lab results and discussion

10

Head to Toe Assessment Time: ________

2

Temp:

Pulse:

RR:

System Assessment tips to help you for each section.

General Appearance: How did you receive the
patient? In bed? In the chair? In the hall? If in the
bed, in what position, supine, right or left side, and
head of bed in degrees. If on a special bed if mattress
addresses this here. Where did the patient come from?
Is the patients significant other involved in the plan
of care? What is the patients mental status -.happy,
sad, cooperative, etc.
Neurological: Is the patient alert, lethargic or
obtunded? Is the patient orientated x 4. If not reorient
to the areas that they are confused about? How is the
pts. affect? Appropriate or inappropriate for the
situation? Is the speech clear? PERRLA ?Smile
symmetrical? ROM and Strength of movement on all
extremities(compare rt. and lt.)Sensations intact? Gait
steady? This is a good area to address pain. Denies
pain.

B/P:

O2 Sat:

Notes

Cardiac:(Start the cardiac assessment with the heart).

S1S2 regular/irregular S1 apically. Radial pulses
strong bilaterally? Pedal pulses weak bilaterally? (If
you cannot feel a pulse get the Doppler) How is the
capillary refill? Is it less than 3 secs to all extremities?
Does the patient have edema? You can put the B/P in
here if you want. A/V fistula? Positive bruit and
thrill?
Respiratory: How is the patient breathing? Is it
labored, regular, unlabored? Does pt. C/O SOB with
exertion? What do the lung sounds like? What do you
hear? Is there sputum or a cough? If so, describe it.
O2? (how many liters a min, and is it nasal, mask,
trach etc. symmetry of the chest?
GI: Describe the abd. Is it firm, soft, distended, and
tender? How are the bowel sounds, normoactive,
hypo or hyperactive. BMs (describe). Appetite. Is
there a NGT or GT w feedings; if so ck placement
and residuals. Example: FS Jevity to rt. nare. Salem
Sump NGT at 60ml/hr via pump w placement
confirmed with aspiration of 20ml and air
auscultation. Ostomy? Describe.
GU: Voids, suprapubic/foley to gravity? Describe the
urine color, amount and consistency. Describe the
genitalia.rash, redness, discharge, drainage, etc
Skin: Is the skin intact or are their wounds and
dressings? If so describe the wound if open, for signs,
drainage, odor, et .and where is it. or is dressing dry
clean and intact? Describe the skin in general. Dont
forget turgor. Did you assess the skin for each of the
systems?
IV sites: Where? Saline lock or IV? Central
lines(where are PICC lines?) Site assessment for
redness, swelling, pain, patency of all?
Equipment: Is there equipment in the room? Jobst
pumps, CPM machine etc. Example: Isolation?
Maintain contact isolation for C-Diff. Look for signs
above the bed for instructions re: BPwhich arm, etc
Safety: Side rails up, call light in reach, Restraints ,
Posey, soft or hard, etc. Is there current orders for
restraints? Safety of the environment?

CALIFORNIA STATE UNIVERSITY, LOS ANGELES

SCHOOL OF NURSING
3

Pain Scale:

Student Assignment Worksheet

Patients Initials:___________
Age:_______ Sex:_________
Rm #: ____ Adm. Date:_____
Adm. Diagnosis: __________
________________________
Surgery/Date:_____________
________________________
________________________
Allergy:_________________
________________________

Student Name:
Routine Medications:

Date:
Other Treatments:
O2 therapy: _________________
Resp. therapy: _______________
Incentive spirometer: _______
Physical therapy: ____________
CPM: ___________________
Renal dialysis: _______________

RN:_____________________
CNA:___________________

Skin/Wound care: ____________

Activity: BR BSC BRP

Assist: Chair Amb ad lib

Foley Cath: _________________

Other: ______________________

Diet:
Other: ______________________
Fluid Restriction:
N/G or G/T feeding:

PRN Medications:

Lab and diagnostic tests/results

(for the dates of care):

I&O:
____________________________
TPR:
BP:
Pain Assessment:

/10
PCA:

O2 Sat: _____ % on _____

IV Site:
EKG:

IV Solution:

ABG:
Rate:
After shift report and initial assessment, ID the nursing problems (diagnoses) that your patient has & develop a care plan.
1.
2.
3.
4.
5.
II. Pathophysiology
A. Pathophysiology:
4

Define the patients diagnosis in your own words. Define appropriate additional diagnoses--after discussion with
your instructor. Indicate their etiology, incidence and pathophysiology. Show the relationship between the
diagnoses. Cite references.
Define and give a textbook description of the surgical procedure occurring during this hospitalization.
Cite references. (Your medical surgical nursing & pathophysiology textbooks are the minimum required.)
ETIOLOGY

INCIDENCE

PATHOLOGY

Huether, S. E.; & McCance, K.L. (2008). Understanding pathophysiology (14th ed.). St. Louis, MO: Mosby.
Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment
and Management of Clinical Problems (9th ed.). St. Louis: Mosby.
B. Textbook signs and symptoms: List the usual textbook signs and symptoms. List related diagnostic

and lab tests commonly used to rule out or confirm this diagnosis, (i.e., x-ray findings are evidence of a
fractured bone). List the complications for the diagnosis and postoperative complications for which
you should assess. Star (*) those signs and symptoms and complications that your patient experienced.
Cite references.
SIGNS AND SYMPTOMS

DIAGNOSTIC AND LAB TESTS

COMPLICATIONS

Jarvis, C. (2004). Physical examination & health assessment. St. Louis: Saunders.
Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment
and Management of Clinical Problems (9th ed.). St. Louis: Mosby.
III. Nursing and Medical Therapy
A. Nursing Care: Indicate the usual textbook Nursing Care required for pts with these medical diagnoses/surgeries.
Cite references.

Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment
and Management of Clinical Problems (9th ed.). St. Louis: Mosby.
B. Diet
Indicate the patients diet. Define and describe it using your diet handout, hospital diet manual and textbook.
Indicate the composition of the diet. Include those foods groups that are desirable, and those that are prohibited.
Indicate the purpose of this diet for this patient. Relate it to the patients condition signs and symptoms and
therapies. Calculate the patients ideal weight, IBW range, compare it to the current weight, and calculate
current weight in % of IBW. Discuss recommendations for weight loss or gain and timing of this
intervention. Calculate the desirable caloric intake and discuss its adequacy of current intake. How many
calories is your pt getting daily from all sources (I.V., TPN, NG, etc.)? Think about % of diet being taken in.
Cite your references. Show your calculations.

Dudek, S. G. (2006). Nutrition essentials for nursing practice (5th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.
7

C. Medications Use med sheet

For each medication:
1. Medication name (generic and/or trade), all classification(s) of the medication, and the physicians order.
2. List the actions and the uses of the medication.
3. Therapeutic dose, route, and frequency.
4. Adverse effects: life-threatening and common side effects
5. Drug interactions and compatibility.
6. Nursing considerations and implications.
7. Explain why this particular patient is receiving these specific medications and treatments and relate them to
your patients signs and symptoms and diagnostic findings.
8. Evaluations: what desired drug effects will you observe?
9. Indicate the number of times your patient received prn meds during his/her hospitalization, & their
effectiveness. Cite your references

D. Other Medical Therapy/Treatments:

List and discuss nursing considerations and implications, why specifically this patient is on this therapy relating
it to your patients signs, symptoms, and diagnostic findings, and the desired effect for which you observe, for
ALL prescribed medical therapies, including IVs, Respiratory therapy, I & O, daily weight, wound/dressing
care, etc.

E.

Lab and Diagnostic Tests Use lab sheet

Attach a separate piece of paper indicating all lab and diagnostic tests done for your patient during
his/her entire hospitalization. Note the dates and time they were done, the patients results and the test
norms. Each specific hospitals norms must be used.
Briefly explain and discuss the patients abnormal values correlating them with the patients diagnoses and
therapies (i.e. drug therapy or surgery). Also note trends (up and down) and postulate why. Cite your reference
for your explanation.

Medication Sheet
Ht:
NAME
Generic/Trade
Generic:
Trade:

Generic:
Trade:

Generic:

Trade:

Generic:
Trade:

ROUTE
/TIME

Dose
ACTION OF DRUG
and
diluent Indication for patient
PO NG IM Usual
Action
IV R Top
dose
Other_____
Time
Pts
Indication for pt.
dose

PO NG IM
IV R Top
Other_____
Time

Usual
dose

Action

Pts
dose

Indication for pt.

PO NG IM Usual
IV R Top
dose
Other_____
Time
Pts
dose

Action

PO NG IM Usual
IV R Top
dose
Other_____
Time
Pts
dose

Action

Indication for pt.

Indication for pt.

Wt:
NURSING CONCERNS

Allergies:
Pertinent
LABS (results
if available)

INTERACTIONS (drug/food)
Major side effects

PT.
RESPONSE

Generic:
Trade:

PO NG IM
IV R Top
Other_____
Time

Usual
dose

Action

Pts
dose

Indication for pt.

Lab Results Sheet

Test

Range

Dat
e

Dat
e

Other Significant Lab

Tests

Identify WNL
Significance

(cultures, blood gases, drug

levels, and other lab tests, etc)

Baselin
e

WBC

RBCs
Hgb
Hct
Platelet

Glucose
Sodium
Potassiu
m
Chloride
BUN
Creatinin
e

CO2

4,50011,000/
mm3
4.2-6.1 x
106/g
11.5-17.5
g/dl
40-52%
150,000400,000
mm3
70-110
mg/dl
135-145
mEq/L
3.5-5.0
mEq/L
98-106
mEq/L
10-20 mg/dl
0.5-1.2
mg/dl
24-30mEq/L
10

Rang
e

Da
te

Identify WNL
Significance

Magnesiu
m

Calcium
INR
PT
PTT

1.3-2.1
mEq/L
9.0-10.5
mg/dl
See lab
result
11-12.5
seconds
60-70
seconds

VII. Nursing Care Plan

NURSING DIAGNOSIS
NANDA

Related to: can be

more than one cause

GOALS/OBJECTIVES
Goal: a broad, general statement

Objectives: patient centered,

specific & measurable,
achievable within a
reasonable time frame
Focus on the manifestations.

NURSING INTERVENTION
Include independent, dependent, and
collaborative nursing interventions,
including patient education.
Focus on the nursing diagnosis &
related to (causes).

EVALUATION & MODIFICATION

Assessment of pts current status
Are goals/objectives achieved?
Are the problems resolved?
Provide evidence by pts current status.

Subjective Manifestations

Any modifications in goals or

interventions to resolve the problem?
Objective Manifestations

11

Patient Teaching

For OTHER nursing diagnoses.

12