Medical History

Student Name - Marchelle Minor Date - 10-02-09

Client’s Initials - mn Room - 405 Client’s Diagnosis: Pancreatitis, New onset Diabetes Mellitus
________________________________________________________________________
* * Write out the findings of your physical assessment. Use proper narrative phrasing including the following data:

1. Admitting Medical Diagnosis: Pancreatitis - new onset Diabetes mellitus II

Obese Hispanic female, age 28 is admitted to the hospital, communicates well in English. She expresses all over
abdomen pain and is guarding. She is moaning with pain, upon palpation there is rebound activity with facial
grimacing. Patient denies nausea or vomiting stated her last meal was yesterday morning and caused abdomen
pain and bloating feeling. Last menstrual cycle was 4 days and regular every 2 weeks. Last bowel movement
was 3 days ago. She acknowledges change in appetite and weight gain. She is without dizziness or night sweats.
Her weight is 215lbs, Blood pressure is 138/86, pulse 100, respirations 22, 99.0 99% saturating on room air. No
known allergies. Patient states this is her first time in the hospital and prior to moving here she lived with her
mother and father in El Paso. Both are alive and healthy.
Current surgery / surgical history; is denied.
Past medical history No history is available
Home medications. None
Disease/preventive care. Patient denies; infectious
History of Present Illness: Drug use: Cannaboid user weekly past 8 years;
Support systems: Father and mother

IMPRESSIONS: Severe Pancreatitis, Severe Dehydration, Leukocytosis , Hyperglycemia, Cannaboid use,

constipation
 PHYSICAL EXAMINATION
General overall condition: Awoke in semi- fowler position, has bilateral 22 gage wrist/hand IVs’ with 24 hours
replacement time/ restart negative for signs or symptom of infiltrate. Right is capped – Left has 0.9ns infusing at
250cc. Robust female, alert x3 respirations are even non-labored. Skin warm dry and intact color is within
normal limits.

1. Vital Signs T 97, Bp, 121/76, P 101, R20

2. Head: Normal symmetrically, scalp clean without lesion, no dandruff
3. Ears: No earache, deafness, tinnitus, no vertigo or discharge
4. Eyes: No diplopia, itching, dry eyes, eye pain or photophobia, orbits normal
5. Nose: Normal membrane pink and moist.
6. Throat: Flexible. Normal pulsations, no palpable thyromegaly, no palpable Lymph nodes, trachea
central, no JVD
7. Nails: Normal, Good capillary refill
8. Skin: Skin is warm dry and intact, color wnls.
9. Neuro Sensation is intact, Cranial nerves II – XII intact
10.Musculoskeletal WNLS No pedal edema Peripheral pulses normal negative joint swelling
11.Respiratory Normal contour of the chest with symmetrical motion. Clear to auscultation bilaterally, No
dyspnea, No pleural rub.
12.Cardiovascular Tachycardia. Normal S1, S2 No murmurs.
13.Gastrointestinal No Scars, Hypoactive bowels sound, 4 quadrants. Pt is very tender in the right upper
quadrant and mid epigastrium, she is complaining of tenderness all over her back and abdomen. Murphy
is negative.
14.Genitourinary Urine positive for cannabis, Foley - Lab
 15.Mouth Normal lips, Buccal mucosa is dry, Normal looking teeth and gums
16.Nose Normal external, septum and turbinates
(3)
Use SCAR charting me
NURSES NARRITIVE : Use correct documentation technique. Document subjective and objective data
at least every two hours. Chart the care and responses of the client during your care. Please include
an opening and ending statement. Sign after each entry.

Preceptor and SN; Initial observation: 08:30a.m. NPO: The patient is alert and able to state her name
and date of birth. She is sitting in a semi- fowlers position with TV on. I introduced myself. as a Sn and stated I
would be working the her nurse: Noted bilaterally 22g peripheral IVs taped, secure and intact, no s/s of redness
or infiltration Left hand heplocked, Right has 0.9ns infusing @ 125cc via pump. Foley to gravity with 300 cc of
light urine. Q4 hr Finger sticks, 264; administered : 4 units of regular insulin per s/s, given sq in right upper
arm. Pantoprazole 40mg IVP. Abdomen large taunt. Daily Vitals signs completed. Noted abdomen large taunt
patient denies pain at this time. Observed patient guarding her stomach with facial expression of pain. I asked
the patient if she would like to have some pain medication and from 1 to 10 what was her pain level? She stated
it was at a 7. Administered Morphine 5 mg Ivp for pain. (alcohol wipe – ns flush before and after med
administered______________________________________________________________________________________MMinor:sn

SN: 09:00 Returned to observe patient; when asked about the pain she stated it was “much better and it
didn’t hurt anymore.” Ice chip at her bedside. Bed in low position- side- rails up x2 call-bell in reach
_____________________________________________________________________________________________MMinor:sn

Preceptor and SN; 09:15a.m. Assessment of patient reveals she is no longer in pain, talking on her phone
 and rubbing her abdomen, I, with permission check her lower extremities, bilaterally warn to touch with full
range of motion, no pedal edema, peripheral pulses normal. No joint swelling. Good capillary refill. No petechiae
or ecchymosis noted._______________________
________________________________________________________________________________________________MMinorsn

SN: 11.15a.m Patent is in bed asleep – snoring; top side-rails up, remains in semi-fowlers position,
respirations easy, non-labored, color within normal limits, resting on her left side. Call-bell remains in
reach.________________________________
_____________________________________________________________________________________________MMinorsn

SN: 12:00 Patients remains pain free as expressed. CBG 150, no sliding scale coverage, Respiration remain
easy non-labored, color within normal limits, as observed q2 hour checks, in no apparent distress at this
time._________________
_____________________________________________________________________________________________MMinorsn

Preceptor and SN; 1250; Report off to preceptor, condition of patient is stable she is pain free at this time.
____________________________________________________________________________________________Mminorsn
(4)
Pathophysiology

1. Disease Name, Definition, Changes in Body Tissues/Organs, Function/Structure:

Pancreatitis: an inflammatory condition of the pancreas that may be acute or chronic. Acute pancreatitis is
generally the result of damage to the biliary tract, as by alcohol, trauma, infection disease, or certain drugs.
It is characterized b y severe abdominal pain (generally epigastic or upper left) radiating to the back, fever,
 anorexia, nausea, and vomiting. There may be jaundice of the common bile duct is obstructed. The
development of pseudocysts or abscesses in pancreatic tissue is a serious complication. The pancreas is an
elongated grayish pink lobulated gland that stretches transversely across the posterior abdominal wall in the
epigastric and hyochondriac regions of the body and secretes various substances, such as digestive enzymes,
insulin, and glucagon. The chronic pancreatitis is similar to those of the acute form.

2. Clients at Risk: A block in the ducts between the pancreas and the liver. This includes gallstones that force
pancreatic fluids to back up, causing inflammation and permanent damage. Tumors, Chemicals in the digestive
system, Inflammation of nearby organs antibiotics, such as sulfa drugs and tetracycline, high exposure to
estrogen and some diuretics, binge drinking or regularly drinking large amounts of alcohol, abdominal surgery
complications from a screening procedure called endoscopic retrograde cholangiopancreatography (ERCP),
Infections (such as mumps or viral hepatitis), high levels of calcium or triglycerides in the blood. People at risk
of gallstones are also at risk for acute pancreatitis. This includes pregnant women, women who have had many
pregnancies and people who are overweight.

3. Effects on Client (signs & symptoms): Symptoms of the acute form include pain upper part the stomach
area. The abdomen is rigid and tender.

SIGNS: nausea, vomiting, bloating, belching, hiccups and/or collapse. The patient may have steady which radiate to
the back, side or lower stomach area. The patient may also have a fever, shortness of breath or kidney problems if
the symptoms are severe. The patient may also be constipated, have a slow pulse and show signs of and show signs
of jaundice.
3. How diagnosed (X-rays, lab test, etc.) Diagnostic Test for Pancreatitis are: computed tomography (CT),
ultrasound of the gallbladder. Abdominal x-rays, 3 series, arterial blood gases, BMP, CBC, Urine Drug screen,
lipase, Hemoglobin A1c
How Treated: Treatment options offered for Pancreatic Diseases include: Noninvasive
photo-dynamic therapy, a treatment for bilary strictures, Drug therapy for all pancreatic disorders, Noninvasive
photo-dynamic therapy, a treatment for bilary strictures, Drug therapy for all pancreatic disorders, Endoscopic
pancreatic therapy to help alleviate pain and improve pancreatic duct drainage in patients with chronic pancreatitis,
Enzyme therapy, which can aid nutritional absorption of food and curb weight loss.

Medications: Cotazym, Pancreatin, Pancrelipase, lipram-Cr20, Pancrease MT– Action- Inhibit pancreatic secretions
4. Expected Outcome (chronic, corrected with treatment, death, etc.): The expected outcomes the patient will be
pain free (opioid analgesia The patient will understand the importance of nutritional planning.

5. Possible Complications: Acute pain relief is the first priority for patients with chronic pancreatitis Diabetes
Mellitus, chronic steatorrhea ,high risk for biliary obstruction a serious and painful complication Disrupted skin
integrity, after each stool use a soothing emollient such as Sween Cream, zinc oxide cream.
6. Specific Nursing Actions: The focus of caring for the patient with chronic pancreatitis is pain management,
assist in maintaining a nutritional intake and prevent reoccurrence. psychosocial adaptation to a chronic illness
and alcoholic abstinence. (www.aa.org) Teach the patient to take the pancreatic enzyme before or at the
beginning of the meal. Disrupted skin integrity, after each stool use a soothing emollient such as Sween
Cream, zinc oxide cream. Surgical management is not a primary intervention for the treatment of chronic
pancreatitis.
7. References (must give page number or exact web address)
1. Mosby’s Nursing Drug Reference by Darlene Como, page 767,768
2. Medical-Surgical Nursing 6th edition by Ignatavicius and Workman page 1378, 1386
3. http://www.cedars-sinai.edu/2204.html

8. Individualize to your client care: This patient will have to make new life changes. She is scared because this is
her first hospital admittance. She must focus on new medical problems. I am hoping social services will help
direct her, she’ll need diabetic consultation, glucometer, supplies, and on-going teaching for her new onset
diseases. A referral to Al-Anon (www.al-anon.org) self help groups, are available to her drug problem.
Education is the key to change for developing a different live style.
 STUDENT: M Minor
Clinical Worksheet MIDLAND COLLEGE
PRIMARY: Cameron
Room:405 Name: m.n MR#00000
DX: DR. Bighook
ALLERGY:NKA DIET: NPO
8:00VS:T99.0 P86 R20 BP138/86 O2 Sat 99% Pain Assessment 7 Tolerable level:
3
12:00VS:T98.8 P R BP121/86 O2 Sat 97% Pain Assessment 0
Tolerable level: 3
ASSESSMENT:Neuro, Skin, Musculo/Skeletel, Resp, Cardio, GI, Gu, Surgical wounds/Dressings, Mental
IV:Sol. D5ns Amount:1000cc rate 250cc

TUBING CHANGE DATE:10/4/09 saline lock IV Site: Left wrist

IVPB: Potassium chloride 40 mg in isotonic 100ml; 25ml per hour
CBG: 7:00 264 4 units regular 11:30140 Coverage: 0
Intake 1550 Output 700
TED Hose: no SCDS: no
Dressing: Type none Location: 0
Observation:
IS: Pulls: Times per hr.
Drain# 1: none Drain #2: none
Bath: cna Oral Care: self
Foley yes Removed no

NG no Patent/ Placement no Removed

Drain none Charged/Drainage none
IV / Restart none Site
MEDS: D5w potassium chloride, morphine 5mg IVP , pantoprazole 40 100 ml isotonic Banana
bag
Nursing Diagnosis:Comfort, alteration in related to disease process as evidenced by complaints of pain
Goal(SMART): Patient will be pain free as verbalized at in of nursing assignment
Diagnostic Procedures: Labs, EKG, X-Rays, etc
List labs, x-rays or other diagnostic tests not listed elsewhere. List dates, normal values, and correlate findings to
your client’s history and current medical problems. Also note any special nursing considerations.
DATE TEST NORMAL PATIENT VALUE/ INTERPRETATIONS
NAME RANGE Diabetic: Potassium loss with
10/02/0 polyuria.
9 Potassiu 3.5 – 5.0 *3.3 Blood test
m Poor potassium intake, increased
excretion of potassium, especially
coupled with poor intake, is the
most common cause of
hypokalemia, diuretics, digitalis,
vomiting, wounds, diarrhea, renal
disease. Nothing by mouth cushing
disease potassium, especially
coupled with poor intake, is the
most common cause of
hypokalemia. shift from
extracellular to intracellular space
is another cause.

*3.652L Blood test

10/28/0 RBC 4.2. 5.4 Low RBC values are caused by
9 many cause;
Hemorrhage, gastric bleed or
trauma
Hemolysis as in glucose 6
phosphate dehydrogenase
dedficiency, hyperocytosis
Chronic illness, tumor or sepsis

*42.22 Blood Test use to

10/02/0 amylase 23 to 85 diagnose;
9 units per Amylase is within normal values.
liter (U/L). use to diagnose Pancreatitis use to
 diagnose (elevated amylase)
Hepatitis (inflammation of liver
leads to elevated amylase)
Gallblader disease (here, the
gallbladder causes secondary
pancreatitis, IV dextrose can
cause of false negative reading;

*250 Blood Test

10/02/0 Glucose 70 - 110 Patient has Diabetes Mellitus
9 Elevated Blood sugar are
caused by many factors;Too
little insulin either as a food or
correction bolus, or basal
(background) insulin Poorly time
insulin injection or pump bolus
Stress (even seeing and being
attracted to someone can
elevate blood glucose!) Illness
Inactivity (being sedentary)Too
much food High fat food meals The
Somogyi Effect High altitude
Insulin resistance or not rotating
injection sites often enough,
Insulin resistance or not rotating
injection site, certain medications
steroids,eExercising without
sufficient water, insulin or snacks

Blood Test * 7 Commom causes

10/02/0 BUN 10 - 20 increased protein catabolism or an
9 excessive protein load. imply pre-
renal azotemia
blood urea nitrogen and serum
creatinine usually rise in tandem;
 the normal BUN: Cr ratio is 10-15:
Disproportionate rises in BUN: Cr
(> 20: 1)

Blood Test *12,365 Normal

10/02/0 lipase 12-70 U/L Common causes: Pancreatitis,
9 Pancreatic cancer, Cholycystitis,
Gastroenteritis
 Medication Sheet

Drug Name (brand & Generic): Morphine, Roxanol

Drug Classification: opioid analgesic Narcotic Schedule II

Desired Effect (Use): Severe pain, Depresses pain impulse transmission at the
spinal cord level by interactiong with opioid

Side Effects(s) (5 Common): respiratory suppression, sedation, headache,

constipation, confusion.

Side Effect(s) (ALL LIFE threatening): addiction-forming, decrease respirations,

coma, death

Nursing Implications (5 Major Ones-Include teaching):

• Pain: location, type, character; give dose before pain becomes severe:
• Bowel status; constipation common
• I&O ratio; Check for decreasing output
• B/P, pulse, respirations, (character, depth, rate)
• CNS changes: dizziness, drowsiness’, hallucinations, euphoria, LOC,
pupil reaction.

Teach patient/ family:

• To change position slowly, orthostatic hypotension may occur
• To report any symptoms of CNS changes, allergic reactions
• To avoid use of alcohol, CNS depressants
• Withdrawal symptoms may occur, nausea, vomiting, crams fever, fainting
anorexia

Compatible with other medications? If no, what medications are non-compatible

Yes, Syringe compatibilities: atropine, benzquinamide, bupicacaine, butorhpanol,

cimetidine, fentanyl ranitidine. scopolamine

Compatible with IV solution? If no, what solution is medication compatible with?

Yes: D5w, D10w, 0.0ns, 0.45nacl, Ringers sol

Amount of solution needed for dilution and rate of administration: After diluting
with 5 ml or more sterile H2O or NS; give 15 mg or less over 4-5 minutes

Reference Book and Page Numbers Mosby’s Nursing Drug Reference 2007 Pge
694-5
Client dose, Route & /Reason….. 5mg, IVP, Pain Management PRN Q2 hours
.
 Medication Sheet

Drug Name (brand & Generic): Pantoprazole, Protonix

Drug Classification: Benzimidazole, Protein pump Inhibitor

Desired Effect (Use): Suppresse gastric secretions, blocks final step of acid
production

Side Effects(s) (5 Common):

• Headache, Insomnia
• Diarrhea,
• Abdominal pain
• Rash
• Hyperglycemia

Side Effect(s) (ALL LIFE threatening): None

Nursing Implications (5 Major Ones-Include teaching):

• GI system: bowel sounds, q8h,
• abdomen for pain,
• swelling.
• Anorexia
• Hepatic studies: AST, ALT, alk phosphatase during treatment
Teaching patient/family:
• report severe diarrhea
• Diabetic patient should know hypoglycemia may occur
• Avoid hazardous activities; Avoid alcohol, salicylates, ibuprofen

Compatible with other medications? If no, what medications are non-compatible

Yes: Plavix, Macrodantin, Inderal

Compatible with IV solution? If no, what solution is medication compatible with?

Yes: 0.9 NaCl, D5, LR.
Amount of solution needed for dilution and rate of administration: Reconstitute with
10 ml 0.9 NaCl Reconstitute with 10 ml 0.9 NaCl

Reference Book and Page Numbers Mosby’s Nursing Drug Reference 2007
page770 -771

Client’s Dose, Route & Reason: 40mg, IVP, Pancreatitis

 Medication Sheet

Drug Name (brand & Generic): sodium Chloride 0.9% (Normal Saline)

Drug Classification: Isotonic fluids

Desired Effect (Use): Same osmolality of plasma

Side Effects(s) (5 Common): Fluid overload

Side Effect(s) (ALL LIFE threatening): None

Nursing Implications (5 Major Ones-Include teaching):

Compatible with other medications? If no, what medications are non-compatible

Yes, morphine, protonix,
Compatible with IV solution? If no, what solution is medication compatible with?
Yes, Compatible with Blood

Amount of solution needed for dilution and rate of administration: 1000cc per bag

Reference Book and Page Numbers http://www.rxlist.com/normal-saline-drug.htm

Client’s Dose, Route & Reason: 0.9 sodium chloride, 250cc hour, IV, continously
Isotonic saline fluids such as 0.9% sodium chloride solution can temporarily expand
the extracellular compartment during times of circulatory insufficiency, replenish
sodium and chloride losses, treat diabetic ketoacidosis, and replenish fluids in the
early treatment of burns and adrenal insufficiency. Because their osmolality is
similar to that of blood, they're also the standard flush solutions used with blood
transfusions. 0.9% Sodium Chloride Injection, USP contains 9 g/L Sodium
Chloride, USP (NaCl) with an osmolarity of 308 mOsmol/L (calc). It contains 154
mEq/L sodium and 154 mEq/L chloride.

The flexible container is made with non-latex plastic materials specially designed for
a wide range of parenteral drugs including those requiring delivery in containers
made of polyolefins or polypropylene. For example, the AVIVA container system is
compatible with and appropriate for use in the admixture and administration of
paclitaxel. In addition, the AVIVA container system is compatible with and
appropriate for use in the admixture and administration of all drugs deemed
compatible with existing polyvinyl chloride container systems. The solution contact
materials do not contain PVC, DEHP, or other plasticizers.
The suitability of the container materials has been established through biological
evaluations, which have shown the container passes Class VI U.S. Pharmacopeia
(USP) testing for plastic containers. These tests confirm the biological safety of the
container system. The flexible container is a closed system, and air is prefilled in
the container to facilitate drainage. The container does not require entry of external
air during administration.

The container has two ports: one is the administration outlet port for attachment of
an intravenous administration set and the other port has a medication site for
addition of supplemental The primary function of the overwrap is to protect the
container from the physical environment.

dxWrapDistLeft95250dxWrapDistRight95250wzTooltip"IV Solution by
Medline"posrelv3fLayoutInCell1fAllowOverlap0fIsButton1fLayoutInCell1
CARE PLAN FORM #______

Student Name_M Minor_____________________Date______ Patient Initials__mn_____________Page ____of_____

ASSESSME NURSING PATIENT INTERVENTIONS RATIONALE EVALUATIO
NT DX SHORT N
(PES TERM * (5)
Format) GOAL
(SMART)
Pt guarding Alteration Pt denies 1. Medicated 1. Avoid Relief
left upper of comfort pain at patient to reduce extended obtained,
quadrant of related to this time abdomen pain and periods Resp, easy
abdomen disease will relieve stress for without non labored,
has pain and process, continue comfort measures. medications per patient
tenderness evidence to *Q2-4hrs
as by observe pt has less
documented expression q2hrs 2. Keep Hob in 2. Decreases anxiety
pain scale 8 of pain until end Semi-fowlers pain on lower Breathing
1 - 10 of shift position and upper easier&
*PRN & daily organs better
communicati
on
Remain 3. Support
pain/ 3. Encourage pt to and stabilize goal
stress, used pillow to abdominal meet.decrea
free splint abdomen area se in
(moving at all To help grimacing,
times ) * Daily decrease less stress
pain observed

4. Assist with ADLs 4. Less pt smiling as

And repositioning movement being
q2 hours and prn equals less assisted
pain. repositioning
and ADls
5. Massage back 5. Help Decrease in
Steatorrhea Alterations prn and *tid 10– relieve pain relaxing
and foul of stool 15 min discomfort Brushing
smelling related to anxiety/stres her hair
stools that Diarrhea,; Pt will 6. Identify pts s sween cream
may decreased have normal bowel pt assess or zinc oxide
increase in peristalsis, minimal status and whether and identifies to area, after
volume as immobility discomfor she requires anti- if diarrhea is each bm :
pancreatic , t from gas diarrhea med on a playing a Relief noted
insufficiency and routine bases. Q role in PTl, immediately
increases liquidy 4hr it’s normal
stool 4-8 symptom in
hours this disease
Pt has blank knowledge process.
facial Deficient
expression Pt verbalized
during CBG 7. Implement Early ability to use
Complete teaching began implementati the
Understan glucometer q am on to glucometer
Prioritized d & pm. familiarize pt
according ing of the disease
to what disease
level from and the
Maslow: CBG
(circle before
choice) shift ends.
1. 1.
Physiol
ogical
2. 2.
Safety
&
securit
y
3. 3. Love
&
Belongi
ng
 4. 4. Self-
esteem
5. (5). Self
-actuali
zation
Lac 08-2009
 Discharge Planning

Activity = Activities as tolerated.

Medications= Patient will be discharged home on anti-diabetic, anti-inflammatory,
and pain medications.
Equipment = glucometer and diabetic supplies,
Treatments or Therapy = follow-up with diabetic in-depth teaching,
management and nutritional consult to be scheduled with Certified diabetic
educator (CDE).
Help needed = Social service consultation, Rehab: Drug use Al-Anon, www.al-
anon.org. and diabetic consult will be scheduled.
Office visits (follow up) = patient should follow up with primary care Doctor upon
discharge.
Diet = low fat, diabetic 1500 cal.
Safety = Patient should have a responsible family member to help her focus and
manage her new life style.
 Grading Criteria for Nursing Care Plan
NAME:______________________
Objectives 3 5 7 10
Documentati Does not Follows Follows correct Follows correct
on completely correct charting tech charting Head to
follow charting focused/assessm Toe assessment
correct technique ent complete and complete and
narrative and up updates Q 2 updates q 2 hours
technique dates Q 2 hours Discharge planning
hours
Assessment 8 Systems 10 Systems 12 Systems are Both objective and
data are reviewed are reviewed and subjective data
and reviewed complete with incorporated all 14
complete and objective and systems are
with complete subjective data reviewed and
objective with complete
and objective
subjective and
data subjective
data
Medications List meds Lists med Lists med with Lists all meds and
given name with uses and all life how it applies to
general threatening side pt’s assessment
uses, but effects data. Lists
uses do not applicable nursing
necessarily interventions such
apply to pt as teaching,
monitoring &/or
assessment with
each
Lab Data Incomplete Lab not Relevant Lab test Lab relevant,
relevant to are not current complete, & shows
Medical Dx progression of
healing/disease
Nursing Not Not correct Dx could apply to Dx applies to pt’s
Diagnosis supported by PES form pt, but not the assessment data
Choice documentati obvious choice
on
Data None listed Omits Some info is Critical thinking
clustering relevant absent for and understanding
(AEB) data selected Dx of Pathophysiology
applied. Reason
for Dx selection
clear
Goal Not Not Goal SMART and Goal
SMART documente partially SMART and
d as done completed documented as
completed even if
evaluation is not
 accomplished.
Interventions Pt-centered, Pt-centered, Patient-centered, Patient-centered,
and timed time frame, actions specific, and
and specific appropriate to appropriate for dx
meet outcomes, & outcomes. Time
4 interventions frame stated. 5 or
listed per more interventions
outcome. listed per outcome.
Includes teaching
and monitoring
nursing
interventions
necessary to
achieve pt
outcomes
Rationale for Incomplete Does not Provides reason Demonstrates
the list apply to for interventions critical thinking in
interventions intervention applying reasoning
s
Maslow None listed Illogical Partially correct Valid

____________Below 70 Make corrections and print copy. Make an

appoint. with your clinical instructor for assistance
____________70 -100 Make corrections and print copy for instructor to discuss
suggestions.
INSTRUCTOR: _____________________
SCORE:__________________________________
 Midland College / A.D.N. Program
RNSG 1462
Clinical Evaluation

Name___________________________________________________Date____________________
Document Satisfactory or Unsatisfactory Comments:
Name Date
Faculty Builds performance on previously learned skills Performanc
e
1. Theoretical knowledge: Bath, Bed, AM Care, Treatments (IS), Theory:
Mobility and Safety.
2. Critical Thinking: Disease Process, Education, Medication Thinking:
Rationale and Adm.
3. Communication: Report, Therapeutic and Interdisciplinary Com:
Communication.
4. Caring: Nurse Advocate, Empathy and Rapport. Caring:
5. Management: Completion of Skills and Documentation. Manage:
6. Professional Behaviors: Confidentiality, Punctual, and Behaviors:
Respectful.
Student Comments: Faculty Comments: Faculty
Comments:

_____Medication Administration:

_____Treatments:
_____Med
Adm:
_____Professionalism:

_____Treatme
____Accepts responsibility for nts:
nursing care:

____Seeks learning opportunities _____Professi

onalism:

____Accepts
resp:

____Seeks
learning
opportunities
Strategies for improving: Recommendations: Recommend
ations:
 _____Clinical Incident Report

_____Attend Skills Lab for

mandatory 4 hour Remediation
due
by_______________________
_____
Incident
Report

_____Mandat
ory Skills
Lab for 4
hour
due
by__________
Faculty Faculty
Signature_______________________ Date
Date___
My signature indicates that I have read the above statements and am aware of my
clinical performance.
Signature Date