Clinical Checklist

TRINITAS
SCHOOL OF NURSING
GUIDELINES FOR CLINICAL REQUIREMENTS
NURE 131
SPRING – 2005
TRINITAS SCHOOL OF NURSING
NUR E 131
This packet contains the materials needed to guide you in completing your clinical
requirements. Each guideline contains criteria and standards that have been
determined by the course faculty. These standards are set in order to assist you in
satisfactorily completing all practical and written requirements for the clinical
and/or skill lab. Should you have any questions regarding completion of these
assignments, please contact the course faculty.
Table of Contents
1. Guidelines for All Written Assignments……………………….. 3
2. Bibliography Cards …………………………………………….. 4
3. Comprehensive Nursing Care Plans …………………………… 6
4. Weekly Assignments ……………………………………………. 10

a. History and Physical Assessment Tool…………………………. 13
5. Skills Performance Testing …………………………………….. 24
6. Community Health Presentation ………………………………. 27
7. Cultural Presentation ………………………………………….. 29
8. Student Portfolio ………………………………………………. 30
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NUR E131
GUIDELINES FOR WRITTEN ASSIGNMENTS
1. All other assignments are to be handwritten in black ink.
2. Proper punctuation, spelling and grammar is to be expected.
3. Illegible papers/cards will not be accepted.
4. Papers with ragged edges and/or stains will not be accepted.
5. Papers and cards should be clearly labeled with the student’s name, course and division.
Example: Jane Doe NURE 131 – Days
6. Papers and cards should be stapled or paper-clipped together.
7. Papers in which clients are referred to should only contain the client’s initials. (no names!)
8. Late papers/cards will not be accepted without prior approval from the instructor.
9. APA (American Psychological Association) Style is to be used for all references. See the
guidelines for Bibliography Cards for an example of APA Style. The reference manual can
be found on reserve in the library, and in the computer and skill laboratories.
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NUR E131
BIBLIOGRAPHY CARDS
Objectives:
Upon completion of these assignments, the student will be able to:
1. identify professional nursing journals
2. locate articles in the current nursing literature to supplement course content from library
and internet; and
3. learn to access existing literature to update clinical nursing information.
Guidelines:
1. Select an article from a professional nursing journal. One article must be related to
gerontological nursing, while the second article must be related to medical or surgical
nursing.
2. Submit the article to your clinical instructor for approval.
3. The format should be on a 5” x 8” index card and include the following information
using American Psychological Association (APA) format. For additional information
refer to: http://apastyle.org
a. Reference Citation
Example:
Badger, J.M. (1994). Calming the anxious patient, American Journal of

Nursing, 94(5), 46-50.
94 = volume number
5 = issue number
46 - 50 = page number
b. Summary of Content
Remember to paraphrase. Any quotes from the article must be properly referenced and
documented. Failure to do so constitutes plagiarism and will be subject to disciplinary
action.
c. Reaction to Article
Include your thoughts on the article and discuss how the article will affect your clinical
practice.
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BIBLIOGRAPHY CARDS (continued)
4. Include a copy of the article with your Bibliography Cards when you submit the
assignment.
5. Due dates will be announced in class and also be found on the course calendar.
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NUR E131
COMPREHENSIVE NURSING CARE PLAN
Objectives:
Upon completion of this assignment, the student will be able to:
1. identify client’s abilities and limitations.
2. select appropriate nursing diagnoses for a chosen client.
3. Formulate realistic short-term and long-term goals with time references.
4. Choose and implement appropriate nursing interventions to achieve the stated goals.
5. Evaluate nursing care based upon the stated goals.
Guidelines:
1. Select one (1) of the clients you have been assigned to care for. The client must be from
your gerontological experience.
2. Identify three (3) nursing diagnoses for the selected client.
3. Care plans should follow the format used in the attached sample and include the following
areas:
a. Abilities
What are the client’s strengths? What factors enhance the client’s ability to perform
self-care?
b. Limitations
What are the client’s weaknesses? What factors make it difficult for the client to
perform self-care?
c. Nursing Diagnosis
Use only approved nursing diagnoses. Be sure to identify the causative factors (related
to…) and the manifestations of the diagnoses.
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NUR E131
COMPREHENSIVE NURSING CARE PLANS (continued)
d. Nursing System
Identify whether the client is wholly compensatory, partly compensatory, or supportive-
educative. It is possible for a client’s care plan to encompass all three (3) systems
depending upon your client’s condition and the diagnosis you have selected.
e. Client Goals
What will the client be able to do as a result of your nursing intervention? Remember
goals must be measurable with time frames. Be sure to include at least two (2) short-
term goals and one (1) long-term goal for each diagnosis.
f. Nursing Actions
List all assessments and interventions needed to accomplish each client goal.
g. Scientific Rationale
For each nursing action identified, give the reason why you included the action. Be sure
to cite the source of your information.
h. Implementation
These are more specific nursing actions. For example, if the nursing action is to
perform range-of-motion exercises 3 times a day, the implementation would be
performed range-of-motion exercises with morning care, at 2:00 p.m., and with evening
care daily. Do not rewrite the exact same nursing action. Be specific about what was
actually done.
i. Evaluation
Were the goals met? This should simply address the attainment of goals not the
implementation of nursing actions.
4. Submit the completed Care Plan along with the History & Physical Assessment Tool you
completed for the client.
5. Due date will be announced in class and can also be found in the course calendar.
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WEEKLY ASSIGNMENTS
Objectives:
Upon completion of these assignments, the student will be able to:
1. perform a basic head-to-toe physical assessment.
2. discuss common diagnostic tests and procedures including the purpose of the test
appropriate pre and post- care.
3. describe commonly used medications including their purpose, major side-

effects, and appropriate nursing care.
4. identify abilities and limitations for each assigned client.
5. develop a plan of care for each assigned client.
6. discuss the basic pathophysiology of common health deviations and the related
nursing care.
Guidelines:
1. For each assigned client, completed the following:

a. History & Physical Assessment Form
b. Nursing Care Plan
c. Client Data Card – Due at beginning of or prior to caring for client
2. Complete the History & Physical Assessment Form as follows:

a. Avoid vague terms such as “good”, “poor” and “normal”. Describe your findings
in detail.
b. Your clinical instructor will discuss each area and determine which areas are to be
completed. NOTE: Certain areas, while not required in the beginning of the
semester may be required later.
c. See sample form attached.
3. Weekly assignments are to be submitted to your clinical instructor at the conclusion of

the second clinical day.
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GUIDELINES FOR THE USE OF CLIENT DATA CARDS
The Client Data Card shall contain the following information:
a. Client’s initials, age, sex
b. Room number
c. Medical diagnosis; Surgery; Date of Surgery
d. Food and drug allergies
e. Medication – date ordered, name of drug, dosage, route and frequency of administration
(classification) (generic name)
f. Use of medication for this patient
g. Diet
h. Activity
i. Treatments ( To be written at the back of card)
j. Anticipatory times for activities such as medication administration, V/S assessment,

dressing changes, and OOB transfers
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TITLE: GUIDELINES FOR THE USE OF CLIENT DATA
EXAMPLE (FRONT OF PATIENT DATA CARD)

M.J. 49 y.o. Male Your Name
Appendicitis; Diabetes Mellitus No Known Allergies
Surgery: Appendectomy Diet: Clear Liquid
Date of Surgery: 9/4/96 Activity: OOB as tolerated
Standing Orders
9/4 ciprofloxacin hydrochloride 500 mg. Po q 12 hrs.
(Cipro) – antinfective
Treatment of Urinary Tract Infection caused by E. Coli
9/4 glyburide micronized 1.5 mg. po OD
(Glynase) – antidiabetic
To control diabetes mellitus
9/4 sertraline 100mg po BID
(Zoloft) – antidepressant
To decrease suicidal ideation and improve depressed mood and withdrawn
behavior.
9/4 lorazepam 1 mg. po q 4 hrs. prn
(Ativan) - antianxiety
To decrease agitated behavior
BACK OF PATIENT DATA CARD

TREATMENT OR PLAN OF CARE
- Blood Accucheck q 12 hours 6 am & 6 pm - Incentive Spirometer Q2 Hr.
- Dressing Change PRN - Restrain PRN
- Intake and Output - Suicidal Precaution
- Daily weight - Fall Precautions
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Understanding Pathophysiology:
Based on the information on your completed pathophysiology cards for all disease processes that
apply to this client, answer the following questions.
How do current disease processes and other chronic disease processes, major surgeries, or injuries
affect each other? (If there is no history of other disease processes, state “Not Applicable”.)
Explain how chronic disease processes, major surgeries, or injuries will affect client’s recovery. (If
there will be no effect, state “None”.)
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Perception of Health Status:
Do not leave any blanks. Write “not applicable” if nothing is found.
___________________________________
Client’s perception (Subjective Statement) of health status and expected recovery.
Significant other’s (Subjective Statement) understanding of health status.
What teaching is required for the client to return to optimum level of functioning?
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Diagnostic Testing:
List the diagnostic tests that were done of this patient. If none, state “None”.
Diagnostic Test Results Purpose Pre & Post Cause for

Client (Normal (Why were these Test Care Abnormal Values
Range) done on your client)
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Medication Record:
Complete the following. Add additional sheet as necessary.
Drug/Dose/Frequency (include Purpose & Action Side Effect Nursing Actions

generic & trade names) (include functional &
Ex: digoxin (Lanoxin) chemical classifications)
Func. Class: inotropic,
dysrhythmic, cardiac
glycosides
Chem Class: digitalis
preparation.
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Intravenous Solutions:
Indicate the IV solutions the client received.
IV Solution flow rate Physiological Action Rationale for Use Nursing Responsibilities
in cc/hr
and gtts/min.
Identifying Nursing Care Problems:
Client’s Assets: (Abilities)
Client’s Deficits: (Limitations)
Identify the nursing problem areas that relate to your client. Star(*) priority problems. Develop
nursing diagnosis based on the starred problems.
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Will include:
A. Three (3) nursing diagnoses.

B. The first nursing diagnosis will incorporate all aspect of the nursing process, i.e., goals,
interventions, rationale, implementations and evaluations.
C. The remaining two (2) nursing diagnoses may or may not require all aspect of the nursing
process as stipulated by the student’s clinical instructor.
Nursing Dx Goals Nursing Intervention/Scientific Rationales
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Nursing Dx Goals Nursing Intervention/Scientific Rationales
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Based on your nursing care plan and the care you actually gave, evaluate your plan of care.
Indicate why one of your nursing interventions was not done, why it might not be appropriate for
this client and how you would later the plan to help meet your stated client goals. If your nursing
diagnosis was not correct, state why. If your goals (client) were unachievable, why do you think
this is so? If you think you did a great job and your care plan was working, tell me why.
Implementation Evaluation
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SKILLS PERFORMANCE TESTING
Objectives:
Upon completion of performance testing, the student will be able to demonstrate the following
skills:
1. Applying a gown, gloves and mask.
2. Cleaning a wound and applying a sterile dressing.
3. Assisting a client out of bed to a chair.
4. Dosage Calculation Competency.*
5. Medication Administration Proficiency.*
6. Administering and maintaining enteral feedings.
7. Inserting a straight or indwelling catheter.
Guidelines:
1. Vital signs and administering medications, and urinary catheterization will be tested by the
course faculty on the days designed on the course calendar.
2. For the remaining skills, students will follow the procedure outlined below:
a. After the skill has been demonstrated in class, the student will make an appointment to
practice the skill in the skills lab.
b. When the student feels comfortable with his/her performance of the skill, he/she will make
an appointment for testing in the skill lab.
c. When the student successfully demonstrates the skill, the skill lab instructor will sign and
date the skills checklist (see attached)
d. Due dates for the successful completion of all skills will be announced in class and can be
found on the course calendar.
* Medication proficiency testing requires passage of the Dosage Calculation test prior to
testing.
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GUIDELINES FOR CLINICAL SKILLS
1. Skills will be tested according to the procedures outlined in Perry & Potter (2003) Clinical
Nursing Skills and Techniques. (5th edition)
2. The skills can be found on the following pages:
A. Applying a gown, gloves and mask …………………………Chapter 31
B. Cleaning a wound and applying a sterile dressing ……… Chapter 32, 35, 36
C. Assisting a client out of bed to a Chair……………………. Chapter 27
D. Measuring Vital Signs ………………………………………. Chapter 9
E. Administering Medications ………………………………… Chapter 16, 17, 18
F. Administering & Maintaining Enteral Feedings …………Chapter 22
G. Managing a client with urinary catheter …………………. Chapter 24
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_______________________
Semester
_______________________
Name
NURE 131
SKILLS PERFORMANCE TESTING
(Comments) Instructor Date

Skill Signature
1. Isolation precautions:
washing hands
applying mask
wearing gown
wearing gloves
2. Cleaning a wound and applying a sterile
dressing.
3. Assisting a Client Out of Bed
4. Measuring Vital Signs

temperature
pulse
respiration
blood pressure
5. Administering Medications.
oral
subcutaneous
intramuscular
6. Enteral nutrition:
verifying tube placement
administering feeding
dressing of skin around feeding tube
7. Managing a client with indwelling urinary
catheter:
insertion
care
removal of catheter
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NURE 131
COMMUNITY HEALTH PRESENTATION
Objectives:
1. identify health problems within a community utilizing many sources including the internet.
2. locate resources to deal with the health problems of a community.
3. develop a proposal to meet the health needs of a community for which there aren’t any
resources available.
4. learn to present or sell an idea to a group of people.
Guidelines:
1. Prepare a 10 minute presentation for the class utilizing aids such as poster board with graphs
and/or pie charts.
2. Survey your community gathering information on the following areas:
a. population: number, ethnic-cultural composition, age and gender.

b. economic trends: socio-economic grouping, employment patterns, local industries.
c. environmental conditions: pollution, airport, highways, garbage, industrial waste, high
tension wires, etc.
d. housing: multiple vs. single dwelling occupancies, availability of government subsidized
housing.
e. major health problems in your community.
f. resources to meet these health problems.
g. what health needs are not being met by existing health resources?
3. Professional attire required. Notify faculty if in need of equipment (eg. Laptop, overhead
projector).
4. Failure to complete the community presentation will result in a clinical failure.
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NURE 131
COMMUNITY HEALTH PRESENTATION (continued)
5. Your presentation should include a brief description of your community and a discussion of the
major health problems in your community along with the resources to meet those problems.
6. Focus your presentation on one unmet health need and your proposal to solve this problem.
Include how you would staff, finance, and market this proposal. Be sure to include cultural
considerations in this proposal.
7. Your classmates will represent your local town council. Your job is to sell the town council on
your proposal.
8. You may work together with the other classmates if they live in the same town as you. Groups,
however, may not have more than four (4) members.
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CULTURAL PRESENTATION
Objectives:
1. discuss the effects of cultural beliefs upon his/her personal health care practices.
2. describe the effects of cultural beliefs upon the health care practices of others.
Guidelines:
1. Prepare a five (5) minute presentation for the class.
2. Discuss the following:
a. your cultural beliefs as they pertain to health care.

b. use of nontraditional health practices (i.e. foods, prayer).
c. attitudes towards traditional health care (i.e. last resort, provider must be of same culture in
order to form therapeutic relationship).
3. Due date will be announced in class and can also be found on the course calendar.
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Students should submit samples of care plans and papers as requested by faculty
for portfolio.
-30-
Client Behavioral Goals Nursing Actions and Scientific Rationale Implementation Evaluation
GOAL Client will: (PC) The Nurse will: Implementation:Goal 1
1 1. Utilize overhead 1. Assess present level of 1. To establish baseline data and
capability ability (lecture notes by ….) Attach nurse’s
trapeze, p.r.n. narrative notes Date________
2. Consult with M.D. to 2. To increase level of activity to
when performing provide trapeze prevent prolonged pressure to Using overhead trapeze
ADL’s 3. Instruct in the use of the one area, Ulrich, p. 74 when reminded
trapeze 3. (Same as above)
4. Encourage the use of the 4. (Same as above)
trapeze q 1 hr:
NOTE: For each additional action you must document a scientific
rationale with text and pages identified, i.e. Burrell, Ulrich, etc.
GOAL 1. Participate in measures 1. Assess entire body area 1. To identify areas of concern Goal II:
11 such as turning to either for skin alterations during Date_______
side with assist q 2 hours A.M care Reddened areas on elbow
and during A.M. care,
2. List all nursing measures 2. To prevent skin breakdown were resolved, no further
i.e. skin care
appropriate to skin care skin breakdown noted or
observed
GOAL 1. Report changes in 1. Assess and measure open 1. To establish baseline data Goal III:
III sensation to sacral area on a daily basis. Date ________
area, p.r.n. 2. List all nursing actions, 2. To facilitate healing 5 cm open area has
i.e.type of dressings and decreased to 4 cm
procedures complaint with
procedures
GOAL 1. Drink fluids: 1. Assess V/S especially 1. To establish baseline data Goals IV & V
IV 1 glass upon arising
temperature and pulse Date_________
and 1 glass with breakfast
V 2. Assess present level of 2. To establish baseline data
2 glasses with lunch Skin turgor has
fluid intake
2 glasses during p.m. 3. To correct poor skin improved. Temperature
3. Provide at bedside
2 glasses during snacks turgor and prevent dehy- is normal (afebrile)
a. pitcher of water dration (Perry & Potter)
b. ginger ale
ABBREVIATIONS: Wholly Compensatory (WC) Partly Compensatory (PC) Support-Educative (SE)
NOTE: DO NOT MOVE ON TO THE NEXT GOAL UNTIL THE FIRST GOAL IS COMPLELTELY CARRIED THROUGH
Sample Care Plan
Dx: 75 year old female with a fracture of the right hip
ABILITIES LIMITATIONS NURSING DIAGNOSIS NURSING SYSTEM: Identify Which

System is Appropriate For Your
Client
Alert Immobile ALTERATION IN SKIN INTEGRITY 1. WHOLLY COMPENSATORY:
Eager to Learn Able To Turn Self With Related to Client is unable to do anything for
Caring Neighbor Assistance PROLONGED PRESSURE ON him/herself and is wholly dependent
Church Open Area On Sacrum TISSUE (Immobility) on the nurse. You would start by
Family (5 cm dia.) saying: Client will show evidence
Physician Reddened Area on Both Manifested by: of…meaning that the resolution was
Nurse Elbows achieved by the nurse.
Student Nurse Poor Skin Turgor 1. Immobile (only able to turn with
Able to Use Upper Temp. 99.4 F assistance) 2. PARTLY COMPENSATORY
Extremities Hard of Hearing 2. Open Area On Sacrum (5 cm. dia.) Client can make contributions or
Able to Turn With Wears Glasses 3. Reddened Area on Elbow assist in their own care by following
Assist Has No Teeth 4. Poor Skin Turgor instructions. (See handout on client
Is Without Dentures 5. Temp. 99.4o F goals.)
Lives Alone
Has No Children Above mentioned manifestation will tell 3. SUPPORT-EDUCATIVE
you the number of client behavioral Client will independently carry out
NOTE: goals, i.e., 4-5 short term goals. nursing measures taught by nurse.
(see handout on client goals.)
All limitations should be
analyzed and clustered NOTE: Your Care Plan may
according to universal encompass all 3 nursing systems
self-care requisites, i.e. depending on your client’s condition,
air, water, etc. i.e., immediate post-op, etc.

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TRINITAS

GUIDELINES FOR CLINICAL REQUIREMENTS

1. Guidelines for All Written Assignments……………………….. 3

2. Bibliography Cards …………………………………………….. 4

3. Comprehensive Nursing Care Plans …………………………… 6

4. Weekly Assignments ……………………………………………. 10

5. Skills Performance Testing …………………………………….. 24

6. Community Health Presentation ………………………………. 27

7. Cultural Presentation ………………………………………….. 29

8. Student Portfolio ………………………………………………. 30

GUIDELINES FOR WRITTEN ASSIGNMENTS

1. All other assignments are to be handwritten in black ink.

2. Proper punctuation, spelling and grammar is to be expected.

3. Illegible papers/cards will not be accepted.

4. Papers with ragged edges and/or stains will not be accepted.

6. Papers and cards should be stapled or paper-clipped together.

Upon completion of these assignments, the student will be able to:

1. identify professional nursing journals

3. learn to access existing literature to update clinical nursing information.

2. Submit the article to your clinical instructor for approval.

Badger, J.M. (1994). Calming the anxious patient, American Journal of

COMPREHENSIVE NURSING CARE PLAN

Upon completion of this assignment, the student will be able to:

1. identify client’s abilities and limitations.

2. select appropriate nursing diagnoses for a chosen client.

3. Formulate realistic short-term and long-term goals with time references.

5. Evaluate nursing care based upon the stated goals.

2. Identify three (3) nursing diagnoses for the selected client.

COMPREHENSIVE NURSING CARE PLANS (continued)

Upon completion of these assignments, the student will be able to:

1. perform a basic head-to-toe physical assessment.

3. describe commonly used medications including their purpose, major side-

4. identify abilities and limitations for each assigned client.

5. develop a plan of care for each assigned client.

1. For each assigned client, completed the following:

2. Complete the History & Physical Assessment Form as follows:

3. Weekly assignments are to be submitted to your clinical instructor at the conclusion of

GUIDELINES FOR THE USE OF CLIENT DATA CARDS

The Client Data Card shall contain the following information:

a. Client’s initials, age, sex

c. Medical diagnosis; Surgery; Date of Surgery

d. Food and drug allergies

f. Use of medication for this patient

i. Treatments ( To be written at the back of card)

j. Anticipatory times for activities such as medication administration, V/S assessment,

TITLE: GUIDELINES FOR THE USE OF CLIENT DATA

EXAMPLE (FRONT OF PATIENT DATA CARD)

BACK OF PATIENT DATA CARD

Perception of Health Status:

Do not leave any blanks. Write “not applicable” if nothing is found.

Client’s perception (Subjective Statement) of health status and expected recovery.

Significant other’s (Subjective Statement) understanding of health status.

Diagnostic Test Results Purpose Pre & Post Cause for

Complete the following. Add additional sheet as necessary.

Drug/Dose/Frequency (include Purpose & Action Side Effect Nursing Actions

Indicate the IV solutions the client received.

Identifying Nursing Care Problems:

Client’s Assets: (Abilities)

Client’s Deficits: (Limitations)

A. Three (3) nursing diagnoses.

Nursing Dx Goals Nursing Intervention/Scientific Rationales

Nursing Dx Goals Nursing Intervention/Scientific Rationales

SKILLS PERFORMANCE TESTING