Question DescriptionSchool of Health Professions, Science and WellnessDepartment of NursingDaily Clinical logSpring 2017Course: __________________________________________________________________________Student: _________________________________ Date: _____________________________Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________Date of Admission: ________________ Date of Care: _____________________________Present Medical Diagnoses: ____________________________________________________Present Surgery (if applicable): _____________________ Date of Surgery: ______________Allergies: __________________________ Code Status: ________________________Vital Signs T_____________ P_____________ R____________ BP______________ SPO2___________General AppearancePsychiatricHEENTNeckBreastsLymph NodesPulmonaryCardiovascularSkinNailsAbdomenGenitourinaryPelvicRectalExtremitiesMusculoskeletalNeurological (DTR’s, reflex grading, cranial nerve evaluation)IncisionsDrainsDiet/NutritionIVsIntake and OutputFall Risk Assessment (include score)Pressure Ulcer Risk Assessment (include score)Pain assessment (include reassessment)Time Score Intervention Reassessment Time Score Diagnostic Assessments – Important EKGs, X-Rays, and LabsLab/Other Test Patient values Inference Medications Administered:MedicationsDose/Brand name/Generic name Indication of use Adverse Effect/Side effect Nursing Implications Treatments and Procedures Day & Times Rationale Nursing Interventions:Assessment Findings Nursing Diagnosis Outcome Nursing Interventions Evaluations Reflections of the day on meeting course objectives:
