Florida Gulf Coast University



Florida Gulf Coast University

College of Health Professions

School of Nursing

Nursing 3465C: Client Care Worksheet

Student: __________________Date(s) of Client Care:____________ Date Turned In: __________

This form is completed on one person for whom you provided care for each week. Please hand in to your practice faculty by the next class day following your practice experience. The purpose of the worksheet is to assist you to plan, organize, revise and record your nursing practice. Use it as a basis for learning.

I. Pre-practice Information

A. Client Demographics:

Client Initials: _______ Room:_____ DOB/Age:______ Gender:______

Marital Status: ________ Ethnicity:______________ Allergies: __________

B. Admitting Diagnosis:______________________________________________________________________

1. Description:

2. Pathophysiology:

3. Signs and Symptoms:

C. Secondary Diagnosis: _______________________________________________________________________

1. Description:

2. Pathophysiology:

3. Signs and Symptoms:

D. Medical Interventions: (Look at the Admitting Orders and/or Kardex).

1. Activity/Restrictions:_________________________________________________

2. Diet/Restrictions:____________________________________________________

3. Physical Therapy:____________________________________________________

4. Respiratory Therapy:__________________________________________________

5. Medications: (Use the back of page, if needed).

|Medication, Dose, Frequency, Route |Rationale for Use |Most Common Side | |Nursing Responsibilities |Indications of |

|& Classification of drug |with this Client |Effects – indicate if your client | | |Effectiveness of |

| |(Must be referenced by journal or |had any of the side effects (*) | | |Medications |

| |text) | | | | |

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6. Coventions to implement:(For example: Vital signs QID; HOB ( 30( at all times; Weigh QD, Wound Care;

Ambulation, Nutritional Supplements; Tube Feedings; Transpersonal Care).

|Coventions |Frequency |Rationale |Evaluation of Effectiveness of |

| | |(Must be referenced by journal or text) |Coventions |

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7. Treatments (Labs, Tubes, Respiratory Therapy, Physical Therapy, etc.):

|Treatment |Frequency |Rationale for Ordering |Nursing Responsibilities |

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I. Clinical Data:

Assessment Data: *Any abnormal finding must be accompanied by a note of explanation. Please supply

Nurses notes any time further explanation is needed.

|PSYCHOSOCIAL |Assessment time: |NOTES |

|Supportive relationships: |(family visits (visitors occas. | |

| |(no family support (SS referral) | |

| |(no visitors observed | |

|Behavior: |(cooperative (pleasant | |

|Mood/Affect: |(resistive to care (agitated | |

| |(combative (calls frequently | |

| |(sad (withdrawn | |

|NEUROLOGICAL |Assessment time: | |

|Level of Consciousness(LOC): |(responds to name | |

| |(responds to pain (comatose | |

|Orientation: |( x4 (person (place | |

| |(date (time (other (see NN) | |

|Communication skills: |(speech clear (speech difficult; | |

| |makes needs known (other (see NN) | |

| |(no speech | |

| |(uses assistive devices | |

|CARDIAC |Assessment time: | |

|Heart rate: |(regular (irregular | |

|(Telemetry (see NN) |(other:_________________ | |

|Heart sounds: |(WNL (other (see NN) | |

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|Edema: | | |

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|Peripheral pulses: |(WNL (altered | |

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|RESPIRATORY |Assessment time: | |

|Respirations: |(easy (dyspnea | |

| |(dyspnea on exertion | |

| |(other | |

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|Breath sounds: |(clear (other | |

| |(crackles: location ________ | |

| |(wheezes: location _______ | |

|Cough: |(none (nonproductive | |

| |(productive (suctioned | |

| |Secretions:______________ | |

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|Oxygen: |(none (______ L /min. | |

| |(cannula (mask | |

| |( Pulse oximetry ______ % | |

|Chest tube: |(NA (functioning | |

|(drainage details described in |(location: _______________ | |

|NN & amount recorded on GRAPHIC|(drainage: ______________ | |

|RECORD) | | |

|Incentive spirometer: |(NA (used as ordered | |

| |(refuses to use | |

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| |(unable to use as directed | |

|GASTROINTESTINAL |Assessment time: | |

|Abdomen: |(soft (firm (distended | |

| |(nontender (tender | |

| |(other | |

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|Bowel sounds: |(WNL (other | |

| |(hypoactive (hyperactive | |

|Bowel movement: |(PO laxative (enema; type | |

|Date last BM ______ |___________________________ | |

| |Results:____________________ | |

|Devices: |(NA (NG tube: position (____ | |

|(drainage details described in |(Ostomy __________________ | |

|NN & amount recorded on GRAPHIC|(GT Feeding: (cont. (bolus | |

|RECORD) |Solution/rate________________ | |

| |(HOB ( _________degrees | |

|GENITOURINARY |Assessment time: | |

|Voiding: |(w/out difficulty (w/difficulty | |

| |(urinary drainage device | |

|Color/Consistency: |(yellow (not observed | |

|(may be recorded at any time |(bloody ( dark/concentrated | |

|during the shift by the |(clear (mucus shreds | |

|assessment nurse) |(sediment (other | |

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|Urinary drainage devices: |(NA (Foley (SP catheter | |

|Insertion date:_____ |( Other: ___________________ | |

| |Catheter care: (self (staff | |

| |Comments__________________ | |

| |___________________________ | |

|MUSCULOSKELETAL & NEUROVASCULAR|Assessment time: | |

|Capillary refill: |(WNL (>3 secs. | |

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|Sensation: |(WNL (altered | |

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|Motor (ROM): |RUE: (WNL (altered* | |

|*altered - Must have a note |LUE: (WNL (altered* | |

|accompanied |RLE: (WNL (altered* | |

| |LLE: (WNL (altered* | |

| |(Amputation (site/s): | |

| |___________________________ | |

| |___________________________ | |

|Devices: |(NA | |

|Please list any devices used | | |

|and state their purpose: | | |

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|INTEGUMENTARY |Assessment time: | |

|Skin temperature: |(warm (cool (hot | |

| |(dry (clammy (diaphoretic | |

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|Skin color/Nailbeds: |(pink (pale (dusky | |

| |(other | |

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|IV Site #1: (NA |(WNL (redness (swelling (leaking | |

|gauge_______ |(drainage | |

|insert date:________ |(site changed | |

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|site:______________ |___________________ | |

| |Rate ____cc/hr. (IVAC | |

|IV Site #2: (NA |(WNL (redness (swelling (leaking | |

|gauge_______ |(drainage | |

|insert date:________ |(site changed (see NN) | |

| |Fluid ___________________ | |

|site:_____________ |Rate ____cc/hr. (IVAC | |

|Skin integrity: |Anterior | |Posterior |

|I = intact |[pic] | |[pic] |

|IV = intravenous site | | | |

|A = abrasion | | | |

|C = cellulitis | | | |

|D = pressure ulcer | | | |

|(see NN for details) | | | |

|E = ecchymosis | | | |

|F = flaking/dryness | | | |

|ST = skin tear | | | |

|W = surgical wound | | | |

|O = see NN for details | | | |

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