clinical package

Question Description

Mobility or Safety
Elimination
Oxygenation: Gas Exchange
Thermoregulation or fluid and electrolytes
Inflammation/infection
Tissue Integrity
Pain

Date:

7/19/2019

Student name:

Clinical Site/Unit:

TCU

Clinical Site Instructor:

Clinical Site Mentor:

George

Overweight/underweight:

Allergies:

No known

Marital Status:

divorce

Religion:

lutheran

Cultural Background:

white

Primary Language:

English

Code status:

Diet/Nutrition:

Activity:

Treatments:

IV/Tubes/Ostomies:

Interdisciplinary Cares (OT/PT/RT):

Dressings/Wounds:

(type & location)

Oxygen:

(delivery method & amount)

Dialysis:

Admitting Medical Diagnosis(s):	Multiple sclerosis
Primary (if different than Admitting)
Secondary (Do not include History Of):	Localize edema

Medication Data Sheet

Scheduled Medications that your patient is currently taking.

Drug Name and Classification	Expected action & indication for use	Side Effects/ Adverse Reactions	Medication/Food Interactions	Nursing Administration Special Instructions & Assessments	Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale
Metoprolol 25mg
MiraLAX
Multi vitamins
Omega 3 fatty acid 1000mg
Aquaphor ointment
Vitamin d 500mg	.
Magnesium 400mg
Bisacodyl suppository 10mg
Camphor menthol lotion
Acetaminophen 650mg

Daily “Brains”, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.

Room #:18

Diet:

Ambulation: wheel chair

IV fluids:

Allergies:

	Medications	Treatments	Nursing care/interventions	Vital Signs
0700		Remove hand splint	Check vital signs Check for constipation	138/70
0800	Calcium Metoprolol Multivitamins Mega 3	Apply oitment
0900
1000	Ensure
1100
1200	Tizzadine 4mg
1300

ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.

Body System
Vital Signs and Pain Level:	138/70 pain level is zero
Sensory:

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