1st Clinical Day

Clinical Orientation

1. Prior to clinical, review clinical objectives and any information relative to clinical
assignments, logs, and DMRs. Bring this information to clinical with you.

2. At the time designated by your clinical instructor, schedule an entry interview. Prior to the
interview, complete the top portion of the Entry/Exit Interview form including the
identifying information and at least one specific objective for the term. You should
particularly focus on problem areas that you need to work on such as charting, assessment,
etc.

3. During tour of assigned units, identify the following:

_____ Supply and equipment storage areas

_____ Medication storage and prep areas
_____ Dirty equipment and laundry areas and procedures for handling these items
_____ Crash cart and other emergency equipment and procedure for calling a code
_____ Location of fire alarms, extinguishers, emergency O2 shutoff valves
_____ Layout of unit
_____ Layout of typical room including supplies and equipment in room, nurses call
system

4. Identify roles and responsibilities of various health team members.

a. What is the role of the RN?

b. Are there LPN’s and CNA’s on the unit and if so, what are their responsibilities?

b. Are there other members of the health team (Respiratory Therapy, Pharmacy, etc.)
located on the unit? If not on the unit, what is the procedure for contacting these
individuals, particularly in a code or crisis situation?

c. How are assignments made, patient issues communicated, etc? In general, what is the
structure, functioning, professional chain of command, etc. within the unit?

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 d. Describe any situation in which you observed delegation activities. Who delegated
what to whom?

5. Identify unit emergency procedures.

a. What is the procedure for calling a code?

b. What is the procedure to follow in case of fire?

6. Review patient’s chart, MAR, Kardex, and other records as available to familiarize yourself
with charting and medication documentation policies and procedures.

a. What type of documents does this facility use to document patient care and
communicate among team members? What is the format of nurse’s notes (narrative,
flow sheets, SOAP format, etc.)?

b. Is the MAR computer generated, electronic or hand-written? What are the standard
medication times for daily, bid, tid, qid, q6h?

7. Describe any processes or practices in place for quality control, standards of safety, Joint
Commission requirements, or other standards to promote optimal patient outcomes and unit
effectiveness.

8. Select one patient, briefly review the patient’s chart, MAR, and other records as appropriate.

a. What is the patient’s diagnosis and why are they in the hospital?

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 b. What does the chart and other records reflect about the patient’s current status and
status for the preceding shift (stability of vital signs, fluid status, PRN medications
needed, etc.)?

c. What stressors, both psychological and physiological, can you identify for this patient
that might create an imbalance in homeostasis?

9. Identify any actual or potential problems of your patient related to impairments in

oxygenation secondary to respiratory disorders.

10. Perform a head-to-assessment on your patient and write a narrative nurses note to describe
your findings. TURN IN THE NOTE IN POST-CONFERENCE.

11. Summary of Clinical Day

Think back on your day and write a reflection of the day. How did your day go? What did
you learn today? Are there things you think you did well? Are there things you thought you
could do differently.

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 Head to Toe Patient Assessment CARDIOVASCULAR STATUS
Rate Apical Radial __________
GENERAL SURVEY
Rhythm Regular Irregular
In Bed In Chair Other
Quality/Strength Strong Weak
NEURO/MENTAL STATUS
Capillary Refill R seconds L seconds
Response Alert Lethargic Unable to arouse
PERIPHERAL VASCULAR STATUS
Orientation Person Place Time Not able to respond
Pedal Pulses Present Absent Equal Bilateral Other L R
Mood Appropriate Inappropriate
_____
Attitude/Behavior Cooperative Hostile Combative Withdrawn
Edema None L R (1+ 2+ 3+ 4+)
Homan=s Sign Negative Positive Bilateral L R _____
VITAL SIGNS I.V. Lines Solution Rate  Pump
Temp ______ Pulse ______ Respirations ______ B/P _______ Pain ______
I.V. Site/V.A.D. Location Appearance ______________
G.I. STATUS
SKIN Oral Mucosa Pink Pale Dry Moist Intact Lesions
Color/Tone Pink Pale Flushed Cyanotic Jaundiced Dentures None Upper Lower Partial plate
Temperature Cold Cool Warm Hot Teeth Condition ________________________________
Condition Dry Moist Clammy/Diaphoretic Abdominal Contour Flat Rounded Scaphoid Protuberant
Integrity Intact Rash Wound Lesions (describe) Abdomen Soft Firm Tense Distended Tender
________________
Bowel Sounds Absent Present (location): RLQ RUQ LUQ LLQ
Turgor Immediate Remains Peaked Taut
Tubes NG G-Tube Other
Abnormalities: ____________________________________________________
Last BM Continent Incontinent
RESPIRATORY STATUS
G.U. STATUS
Rate _______
Bladder Nonpalpable Distended Continent Incontinent
Rhythm Regular Irregular
Catheter (if present) In place Patent and draining
Ease/Effort Nonlabored/Easy Labored
Urine Color Pale Straw Yellow Amber
Depth Shallow Normal Deep
Character Clear Cloudy Odor
Character Quiet/Silent Noisy
Genitalia/Meatus Redness Discharge Lesions Edema 
Chest Expansion Symmetrical Asymmetrical
MUSCULOSKELETAL/NEUROLOGICAL
Breath Sounds Clear Abnormal Bilateral Other
Movement/Gait Erect Steady Smooth & coordinated Weak
Cough None Nonproductive Productive*
Flaccid
*Describe: Odor Color Consistency __________
Strength Weak Able to turn self in bed Bears own weight
O2 (via) @ L per min.
Hand Grasp/Grip Weak Firm Strong Bilateral Other
Range of Motion Full Limited (describe):
__________________________

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STUDENT NURSES NOTES

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