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RN PROGRAM

MED/SURG NURSING CLINICAL CHEAT SHEET


Student Name: __________________________

Clinical Date: __________________________

Clinical Site and Unit: _____________________

Patient Initials: __________________________

Age: __________________________

Legal Status: __________________________

Height: __________________________

Sex: __________________________

Weight: __________________________

Last Menstrual period: ___________________

Pain: __________________________

Allergies: __________________________

Chief Complaint:
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History of Present Illness:
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Past Medical History:
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Current Orders:
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Diet: ________________________________________________________________________________
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Activity: _____________________________________________________________________________
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Treatments:___________________________________________________________________________
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ASSESSMENT
(Please be specific)

Neurologic:

Appearance/ Activity/ LOC: (level of consciousness)


PERRLA: (pupils equal, round, and reactive to light, accomodation) look/gaze
Orientation: (x4, time, person, place, and situation)
Speech:
Neck: (ROM tenderness, holds head, nodes, glands, swelling, masses) pulses
Inspect Neck: JVD presence
Pain: (descriptive pain, not a scale, reassess pain, and its consistency)
Pediatric:
Fontanels Anterior and Posterior: soft/flat/firm up to 18 months, otherwise N/A
Reflex: Suck/swallow reflex as well as root/gag
Birth weight:
Delivery: Vaginal or c-section
Environment age appropriate:
Cranial Nerves:
I: Patient can smell the lotion I put on his/her face
II: Patient can tell me how many fingers I hold up
III: Pupils react to light normally
IV: Extraocular movement intact
V: Patient can feel touch on different parts of the face
VI: Patient can move eyes in all directions
VII: Patient can smile, wrinkle face, puff cheeks, and grit teeth
VIII: Patient can hear when I snap
IX: Patient can swallow and say ahh
X: Patient has gag reflex
XI: Patient can shrug shoulders
XII:Patient can stick out tongue and move side to side
(reassess if an intervention was performed)

Respiratory:

Inspection: Chest symmetry, shape, position with breathing, air exchange


Breath sounds: bilaterally
Cough: (present, productive)
Sputum: (color, amount, and consistency)
Trachea: midline
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Color:
Tubes:
O2 and SATs:
Difficulties: SOB, accessory muscles, retractions, anxiety
Cry for age: strong for age/weak/high pitched
Upper Airway:
(reassess if an intervention was performed)
Cardiovascular:

HR:
Rhythm: (regular, weak, or strong)
Apical pulse: normal for age and what is normal for age of your patient?
capillary refill: < 3 sec
Heart sounds 1-5 points:
Artificial devices:
Peripheral Pulses (+2-+3 intensity): (distal, pedal, equal, strong, or weak)
Pitting/Edema 1+, 2+, 3+: (present at torso or extremity)
Insertion sites, tubes, lines:
Skin turgor: (assess mucus membranes)
(reassess if an intervention was performed)

Gastrointestinal: Dentition: (pts teeth)


Abdomen appearance: (soft, round) (palpate for tenderness or masses)
Tubes:
Bowel Sounds: (location, x4 quadrants, hyperactive, hypoactive, or normal)
Stool: last BM (color, consistency, amount, date, texture, painful defecation how
many BM a day or if appropriate diaper changes.)
Occult blood:
Ostomies: (stoma location, appearance)
(reassess if an intervention was performed)
Genitourinary:

Urethra drainage devises:


Foleys: urine amt in bag
Urine: (color, odor, consistency, sediment, frequency, voids, continent or incontinent,
any difficulties)
Secondary Sexual Characteristics development: (age appropriate and only by
patient/family permission)
(reassess if an intervention was performed)

Musculoskeletal: ROM: (active, passive) paralysis, strengths, weaknesses, grips, gait, appearances,
skeletal muscle defects)
Peripheral Pulses: (tubes/lines, casts,)
Muscle strength: (reflexes, coordination, sensations)
Vertebral column: (symmetry, normal curvature, Scoliosis, Lordosis, etc)
Mobility: Good muscle tone in all 4 extremities including tone with age appropriate
gross and fine motor skills
(reassess if an intervention was performed)
Integumentary:
3

Skin: (color, integrity, temp, moisture, texture, turgor, insertion sites, dressings,
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bruising, purpura, rashes,)


Hair: ( texture, parasites, hygiene)
Nails: ( color, texture, shape, cap refill)
Umbilical Cord: (Newborns)
(reassess if an intervention was performed)
Psychosocial:

DEVELOPMENTAL ASSESSMENT
PIAGETS STAGE: (defn/citation)
EVIDENCE: (list/identify)
ERIKSONS STAGE: (defn/citation)
EVIDENCE: (list/identify)
Cultural and Spiritual Beliefs: (What is clients/family stated religion? Where is
client from? Be alert of their ethnicity, customs, traditions and background. Tell us
how your clients cultural and spiritual belief effects their nursing care.)
Document:
Family dynamics: (patient/family complaints, concerns) (parental/guardian
interactions with pt, healthcare interest, home situations, Does pt feel safe in the
home?)
Substances: Any excessive alcohol use, or excessive drug use, prescription or nonprescription, smoking or family issues with the above)
Behavior: (mood and affect)
Appearance: (hygiene, age, position, posture, expression)
Significant Relationships:
Support Systems:
(reassess if an intervention was performed)

Nutritional:

Diet: (Special diets, appetite, percentage of food eaten, ability to feed self, breast feed,
breastfeeding feeding tubes, formula, feeding schedule. TPN food allergies)
Nutritional Supplements: (ensure, etc.)
Significant weight loss or gain in last 30 days:
(reassess if an intervention was performed)

Drug

Doseage

MEDICATIONS
Route

Indication

TCD/10-07

CBC
Name
WBC (K/ul)
RBC (M/ul)
Hemoglobin (g/dl)
Hematocrit (%)
MCV (Fl)
MCH (PG)
MCHC (g/dl)
RDW (%)
Platelet (K/ul)
MPV (Fl)
Granulocytes
Lymphocytes
Monocytes
Eosinophils
Basophils
Ab. Granulocytes
Ab. Lymphocytes
Ab. Monocytes

DATE:
Pt. Values

4
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Ab. Eosinophils
Ab. Basophils
Ab. Granulocytes

LAB DATA & DIAGNOSTIC EVALUATION


BMP
Normal values
Name
4.5-10
Sodium (MMOL/L)
4.5-5.5 M (4-4.9 F)
Potassium(MMOL/L)
13-16 M (12-15 F)
Chloride (MMOL/L)
41-50 M (36-44 F)
CO2 (MMOL/L)
80-100
AnionGap(MMOL/L)
26-34
Glucose (Mg/Dl)
31-37
BUN (Mg/Dl)
<14.5
Creatinine (Mg/Dl)
100-450
BUN/Creat. Ratio
3.4-10.4
GFRAA(mL/min/1.73)
55-75
GFRNA(mL/min/1.73)
20-45
Calcium (mg/dl)
0-12
Total Protein (G/dl)
0-4
Albumin (G/dl)
0-2
Globulin (G/dl)
A-G Ratio
Biliruben (mg/dl)
Athline Phosphate
(U/L)
AST/SGOT (U/L)
AST/SGPT (U/L)
TSH (MCU/ml)

DATE:
Pt. Values

Normal values
136-145
3.5-5.5
100-108
21-32
5-15
74-99
7-18
0.6-1.3
12-20
>60
>60
8.4-10.4
6.4-8.3
3.5-5.0
2.0-4.0
1.1-2.6
0.2-1.2
25-115
10-37
5-40
136-145

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS


List all nursing diagnosis relevant to patient condition & based on assessment

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5.
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TCD/10-07