Lamar State College Port Arthur Upward Mobility Program RNSG 2361 Clinical Case Study Student: Date: Instructor: Submit Clinical Case Study in RNSG 2361 Module 8 assignment area. Objectives to be met 2 1 0 Points Earned Patients initials, age and identifiers appropriate to HIPAA Information violates HIPAA
Appropriate medical terms and/or abbreviations used throughout 1-2 Inappropriate medical terms and/or abbreviations used >2 Inappropriate medical terms and/or abbreviations used
Source is documented Source is not indicated in 1 instance Source is not indicated in >1 instances
APA format is correctly used throughout case study APA format is incorrectly used in 1-2 instances APA format is incorrectly used in >2 instances
4-3 <3-2 <2-0 Points Earned In-depth present medical history complete Present medical history missing significant details Present medical history not included
In-depth past medical-health history complete Past medical-health history missing significant details Past medical-health history not included
Activity, Exercise complete Activity, Exercise missing one assessment criteria Activity, Exercise missing > one assessment criteria
Nutrition, Elimination, Metabolic complete Nutrition, Elimination, Metabolic missing one assessment criteria Nutrition, Elimination, Metabolic missing > one assessment criteria
Comfort, Function complete Comfort, Function missing one assessment criteria Comfort, Function missing > one assessment criteria
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 2 4-3 <3-2 <2-0 Points Earned Reproduction, Sexuality complete Reproduction, Sexuality missing one assessment criteria Reproduction, Sexuality missing > one assessment criteria
Psychosocial History complete Psychosocial History missing one assessment criteria Psychosocial History missing > one assessment criteria
Cultural Assessment complete Cultural Assessment missing one assessment criteria Cultural Assessment missing > one assessment criteria
Discharge Information complete Discharge Information missing one assessment criteria Discharge Information missing > one assessment criteria
Nurses Notes complete with appropriate opening entry, a well written entry at least every 2 hours, and an appropriate closing entry; each entry properly signed Nurses Notes missing appropriate information in one of the following: opening entry, a well written entry at least every 2 hours, and an appropriate closing entry; each entry properly signed Nurses Notes missing appropriate information in >1 of the following: opening entry, a well written entry at least every 2 hours, and an appropriate closing entry; each entry properly signed
Primary & Secondary Diagnoses pathophysiology, treatments, medical interventions, and nursing assessment properly discussed Incomplete information in one area: Primary & Secondary Diagnoses: pathophysiology, treatments, medical interventions, and nursing assessment Incomplete information in >1 area: Primary & Secondary Diagnoses: pathophysiology, treatments, medical interventions, and nursing assessment
Medications listed correctly with generic & brand name; dosage, route, frequency, indications for patient, significant adverse reactions, and appropriate nursing interventions Incomplete information in one area: Medications listed correctly with generic & brand name; dosage, route, frequency, indications for patient, significant adverse reactions, and appropriate nursing interventions Incomplete information in >1 area: Medications listed correctly with generic & brand name; dosage, route, frequency, indications for patient, significant adverse reactions, and appropriate nursing interventions
Lab Studies correctly identifies lab tests, normal values, admission & most recent patient values indicating H, L, N, significance to this patient, and nursing responsibilities Incomplete information in one area: Lab Studies correctly identifies lab tests, normal values, admission & most recent patient values indicating H, L, N, significance to this patient, and nursing responsibilities Incomplete information in >1 area: Lab Studies correctly identifies lab tests, normal values, admission & most recent patient values indicating H, L, N, significance to this patient, and nursing responsibilities
Diagnostic Exams identified with results in students word, nursing responsibilities and implications for patient Incomplete information in one area: Diagnostic Exams identified with results in students word, nursing responsibilities and implications for patient Incomplete information in >1 area: Diagnostic Exams identified with results in students word, nursing responsibilities and implications for patient
Minimum of 5 appropriate NANDA problems identified, properly written, and properly prioritized with Top 3 nursing diagnoses further developed One error in: Minimum of 5 appropriate NANDA problems identified, properly written, and properly prioritized or only 2 nursing diagnoses further developed >1 error in: Minimum of 5 appropriate NANDA problems identified, properly written, and properly prioritized or only 1 nursing diagnoses further developed
Subjective & objective data included that are defining characteristics of nursing diagnosis Either Subjective or Objective data are missing on one or more of care plans Both subjective & objective data are missing on one or more of care plans
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 3 4-3 <3-2 <2-0 Points Earned Well written Goals which include: Appropriate short term and long term goals; outcomes that are: specific, realistic & measurable, a definite time frame for achievement, and consideration of patients desires & resources Goals include all but one of criteria: appropriate short term and long term goals; specific, realistic & measurable, a definite time frame for achievement, and consideration of patients desires & resources Goals missing >1 of criteria: appropriate short term and long term goals; specific, realistic & measurable, a definite time frame for achievement, and consideration of patients desires & resources
Interventions: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount; include a rationale, source & page number; and are indicated as (I) Independent or (C) collaborative Interventions include all but one of criteria: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount; include a rationale, source & page number Interventions missing >1 of criteria: relate to the goals; are specific and clearly stated to include: Who performs, how, when, where, time/frequency, & amount; include a rationale, source & page number
Interventions are properly labeled as (I) Independent or (C) collaborative One intervention is not labeled as (I) Independent or (C) collaborative or one intervention is incorrectly labeled >1 intervention is not labeled as (I) Independent or (C) collaborative or >1 interventions is incorrectly labeled
Appropriate evaluations are included for short term and long term goals Inappropriate or incomplete evaluations for 1-2 short term or long term goals is present Inappropriate or incomplete evaluations for >2 short term or long term goals is present
Clinical Log is appropriately completed with all areas offering substantial information Clinical Log is completed with one area offering less than substantial information Clinical Log is not complete or >1 area offers less than substantial information
Correct spelling and grammar used throughout 1-2 errors in spelling and/or grammar >2 errors in spelling and/or grammar
Late Penalty: 25 points up to 24 hours Greater than 24 hours will result in a zero for the assignment
Comments:
Total Points Earned (maximum of 100)
Late Points Deduction Failure to submit electronically as an attachment in proper format (MS Office Word) with grading rubric as first page of document Points deduction (maximum of 10 points)
Final Score RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 4 Patient Information Patient Initials: Age: Admissi on Date: Date of Care: Room: Medical Diagnoses: Information obtained from: Patient Spouse Other
Can you speak English? Yes No Can you read English? Yes No Are you able to read lips? Yes No
Native Language? Do you speak or read any other language?
History of Present Illness (Include date of onset, initial signs and symptoms, course of illness from onset to present and current status of illness):
2014 Lamar State College Port Arthur Page 6 Speech: Clear Slurred Stutter Difficult to Understand Laryngectomy Other Aphasia Type: Describe Variance:
Pupil Reaction: PERRLA Right: Left: Size (highlight) 1 2 3 4 5 mm Size (highlight) 1 2 3 4 5 mm Brisk Sluggish Brisk Sluggish NR NR Other Other Describe Variance:
Eyesight: Normal Nearsighted (Myopia) Farsighted (Presbyopia) Wears Glasses Contacts Blurred Diplopia Glaucoma Blind: OD OS Describe Variance:
Hearing: Normal Hard of Hearing (Presbycusis): Left Ear Right Ear Uses Hearing Aid: Left Ear Right Ear Deaf: Left Ear Right Ear
Neurological: RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 7 Normal Motor Disturbances Seizures Tremors Headaches Numbness Tingling Other: Describe Variance: Glasgow Coma Scale (GCS) Activity Score Patient Score EYE OPENING Spontaneous To sound To pain None
Eyes open, not necessarily aware = 4 Non-specific response, not necessarily to command = 3 Pain from sternum/limb/supra-orbital pressure = 2 Even to supra-orbital pressure = 1
MOTOR RESPONSE Obeys commands Localizes pain Normal flexion (Withdrawal) Abnormal flexion Extension None
Follows simple commands = 6 Arm attempts to remove supra-orbital/chest pressure = 5 Arm withdraws to pain, shoulder abducts = 4 Withdrawal response or assumption of hemiplegic posture = 3 Shoulder adducted and shoulder and forearm internally rotated = 2 To any pain; limbs remain flaccid = 1
Converses and oriented = 5 Converses but confused, disoriented = 4 Intelligible, no sustained sentences = 3 Moans/groans, no speech = 2 No verbalization of any type = 1
Patient Total Score
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2014 Lamar State College Port Arthur Page 8 Activity/Exercise Respiratory: No Cough Cough Non-productive Productive Describe (color, characteristics, amount): Dyspnea: At Rest With Exertion Orthopnea: # of pillows used: Requires HOB increase
Tachypnea Pursed lip
Breathing Pattern: Non-labored Labored Symmetrical Asymmetrical Periods of Apnea Describe Variance: Oxygen delivery mode: Room Air NC Mask (type) Trach collar Other Pulse Oximetry on: On Room Air % (result) O 2 type of delivery mode % (result) Breath Sounds: Clear/Equal Bilaterally R L Location Crackles Rhonchi Wheezes Diminished Absent Describe Variance:
Heart Sounds: Audible S 1 S 2 Murmur Extra Sounds Describe Variance:
EKG Rhythm: (per chart) None in chart, none performed Pacemaker Type: Describe Variance:
Pulses: (A) Absent (W) Weak (S) Strong (D) Doppler Carotid: Right Left Brachial: Right Left Radial: Right Left Femoral: Right Left RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 10 Popliteal: Right Left Post Tibial: Right Left Dorsal Pedis: Right Left JVD Describe Variance:
Capillary Refill: (# of seconds) UR UL LR LL
Extremities: Color: WNL for patient or describe UR UL LR LL Temperature H (hot) W (warm) C (cool/cold) UR UL LR LL Calf tenderness: Right Left Describe color change with positional changes:
Activities of Daily Living: Identify as (I) Independent (A) Assist (D) Dependent Feeding Bathing Grooming Toileting Dressing RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 11 Other Describe Variance: Mobility: Ambulatory Ambulatory w/ assistance Transfer w/ assistance Bed to Chair Bed rest Other
Activity Tolerance: No Problem Weakness Fatigue Dizziness Light-headed DOE Describe Variance: SCD's TED's Other Fall Risk Assessment Check all applicable items and add scores. Age (1) 0-3 years (1) 65-79 years (2) 80+ years History of Fall (0) No Falls (2) Recent 1-2 Falls (4) Fall this hospitalization or is reason admitted Misc (3) Post-op Less 48hrs (5) Needs Constant Supervision
Mental Status (0) Oriented / Comatose (2) Confused / Abusive (4) Intermittent Confusion (3) In Denial Illness / Deficit (4) Agitated / Violent and/or Disoriented / Impulsive Elimination (0) Independent / Continent (1) Catheter (2) Frequency / Nocturia (4) Needs Assistance (5) Independent and incontinent Communication (0) English (1) Non English (2) Aphasia / Short term memory loss Meds/Drugs (3) Antihypertensives (2) Diuretics (2) Laxatives / GI Meds (3) Sedatives / Narcotics / Alcohol Physical Impairment (1) Cane / Walker (2) Visual / Perceptual Impairment (1) Hearing Loss (2) Orthostatic Hypotension / Dehydration (3) Vertigo / Dizziness (3) Confined to bed, chair, restraints (3) Paralysis / Needs Assistance (4) Seizure disorder RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 12 Plan For Prevention (Select All That Apply) Safety Check Protocol Restraints Bed Alarm Protective Devices Floor Mats Safety Levels Level I 0-6 points Level II 7-14 points Level III 15+ points
Patient Fall Risk Score
Identify and discuss in-depth safety concerns for your patient. Safety Concerns: Nutrition/Elimination/Metabolic Height: / (in/cm) Include both Weight: / (lbs/kg) Include both Ideal Body Weight: / (lbs/kg) Include both
General Appearance: Well-nourished Obese Thin Cachectic Other Describe Variance:
Recent Weight: No Change Loss Gain Intentional How much? (lbs/kg) Over what amount of time? Describe Variance:
2014 Lamar State College Port Arthur Page 14 Distended Gravid Firm Rigid Cramps Pain Masses Gas Describe Variance: NG LIS LCS Drainage (color, characteristics, amount):
Bowel Sounds: X 4 Quads Normal Hyperactive Hypoactive Absent Describe Variance:
Stool: Continent Incontinent Hemorrhoids Blood in stool Ostomies: Colostomy Ileostomy Other Last BM: Usual Pattern: Describe stool or ask patient to describe (color, characteristic, amount, frequency):
Stoma: Describe (color, size): Skin: Intact Other Describe Variance:
Bladder: Continent Incontinent Frequency Urgency Retention Dribbling Burning Dysuria Anuria Nocturia Distention Other Describe Variance:
Urine: Clear Dark Cloudy Bloody RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 15 Concentrated Odorous Other Describe urine or ask patient to describe (color, characteristics): Condom catheter Foley catheter I/O Catheter How often? Suprapubic catheter Urostomy Nephrostomy tube CBI Describe Variance: 24 hour I & O: I O (cc) Dialysis Access Location and type: Comfort/Function Vital Signs: Temperature: (site ) Respirations: B/P: Left arm Right arm Other Lie: Sit: Stand: Pulse: Left arm Right arm Other Lie: Sit: Stand:
Sclera: White Jaundiced Red Other Describe Variance:
Skin: Intact Color appropriate to patient Warm Dry Pale Flushed Clammy Diaphoretic Cyanotic Jaundiced Dusky Mottled Hot Cool/Cold Other Describe Variance: Turgor: Elastic Tenting Describe Variance: RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 16 Rash Scar Wound/Ulcer Lesion Petechiae Ecchymosis Hematoma Incision(s) Other Location Description
For incision(s): Edges well approximated Open Inflammation Redness Drainage Sutures Staples Other Describe Variance: Drain(s) Type:
Drainage of wounds and drains: Site Amount Color Characteristics Location Type
Dressings: Site Location Type Condition
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 17
Braden Scale Maximum score 23 = little or no risk If Braden score is 15-18 = at risk If Braden score is 13-14 = moderate risk If Braden score is 10-12 = high risk If Braden score is 9 or below = very high risk Clinical Condition Parameters 1. Sensory Perception: Response to Pressure-Related Discomfort Completely limited (Unresponsive, quad, coma) 1 Very limited (Responds only to painful stimuli, paraplegic, semi-coma) 2 Slightly limited (Responds with some sensory impairment, CVA) 3 No impairment (No limiting sensory deficit) 4 2. Moisture: Degree to Which Skin Is Exposed to Moisture Constantly moist (always incontinent, two or more linen changes every eight hours) 1 Moist (often incontinent, linen change every eight hours) 2 Occasionally moist (Seldom incontinent, linen changes two every 24 hours) 3 Rarely moist (Skin is dry, routine linen change) 4 3. Activity: Degree of Physical Activity Bed rest (Confined to bed) 1 Chairfast (Minimum weight bearing, ambulatory w/assist) 2 Walks occasionally (Ambulatory short distance, sits mostly) 3 Walks frequently (Ambulatory outside room, BID) 4 4. Mobility: Ability to Control, Change Body Position Completely immobile (Cannot move self) 1 Very limited (Makes insignificant movements) 2 Slightly limited (Makes slight changes independently) 3 No limitations (Makes major, independent changes) 4 RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 18 5. Nutrition: Usual Food Intake Pattern Very poor (NPO, IV greater than five days, less than 1/3 meals) 1 Probably inadequate (Needs assistance, less than meals) 2 Adequate (TPN, enteral feeding, greater than meals) 3 Excellent (No supplement, eats most meals) 4 6. Friction and Shear: Ability to Maintain Body Position Problem (Requires complete assist, slides down in bed/chair) 1 Potential problem (Requires maximum assist, sometimes slides down in bed/chair) 2 No apparent problem (Moves independently, maintains good position in bed/chair) 3 Total Score
Implications for this patients plan of care (include need for pressure reduction device(s) and preferred type, nutrition, skin care, and any other appropriate measures) Be specific and in-depth:
Parenteral Access: None #1 Site: IVF (Type) Rate Peripheral lock Location: Central (Type) PICC Line Peripheral Other Type of Access (IV Cath size & length): Without redness, swelling, or pain IV patent Dressing dry and intact Red Warm Swelling Tender Bleeding Drainage Other RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 19 Describe Variance:
#2 Site: IVF (Type) Rate Peripheral lock Location: Central (Type) PICC Line Peripheral Other Type of Access (IV Cath size & length): Without redness, swelling, or pain IV patent Dressing dry and intact Red Warm Swelling Tender Bleeding Drainage Other Describe Variance:
Epidural Access: None Infusion Medication: Rate:
Posture: Straight/Erect Kyphosis Scoliosis Lordosis Other Describe Variance:
Gait: Steady Unsteady Describe Variance:
Assistive Devices: None Cane Crutches Prosthesis Wheelchair Other Describe Variance:
Joints: Full mobility per active ROM Full ROM per passive ROM RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 20 Limited mobility Contractures Limited ROM Pain Swelling Tenderness Stiffness Other Describe Variance:
Muscles: Symmetry Weakness Flaccid Cramping Spasms Other Describe Variance:
Strength: (S) Strong (M) Moderate (W) Weak (A) Absent (E) Equal RUE LUE Equal Unequal RLE LLE Equal Unequal
Grips: R L Equal Unequal
Pain: None Location: Rating (1 to 10): Description: Constant Intermittent Aching Burning Cramping Stabbing Dull Throbbing Heavy Crushing Sharp Other Describe Variance:
Sleep: # of hours: Rested Does not feel rested after sleep Difficulty falling asleep Difficulty staying asleep Naps Usual Sleep Pattern: Other Describe Variance: RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 21 Reproduction/Sexuality Gender: Female Completes self-breast exam: Yes No Last mammogram: LMP: Post-menopausal Birth Control method:
Last Pap Smear: G P A Gyn Surgery: Gyn Problems: Describe Variance: Male Circumcised: Yes No Completes self-testicular exam: Yes No Describe Variance: Psychosocial History What is causing the most difficulty or stress in your life?
How do you deal with this? Do you have friends or relatives that you can call on for help?
Are you very involved in a religious or social group?
Do you feel that God (or a higher power) provides a strong source of support in your life?
Are there any spiritual/religious practices that need to be followed while you are hospitalized? No Yes If yes, What are they? Do you use tobacco? No Yes If yes, What type? How often? RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 22 How long in use? How long have you been tobacco free? Do you use alcohol? No Yes If yes, What type? How often? How long in use? How long have you been alcohol free? Do you take any drugs, herbs, or supplements that are not prescribed? No Yes If Yes, please explain: Stage of Development (Erickson) AEB (Identify stage of development, indicate which stage your patient is in, and provided supporting evidence): Cultural Assessment Country of birth? Years in this country (If an immigrant or a refugee, how long has the patient lived in this country? -You are not questioning legal status.) What setting did you grow up in? urban suburban rural What is your ethnic identity (i.e., Italian-American, Jewish, Texan, Vietnamese)?
Who are your major support people? family members friends other Who are the dominant family members? Who makes major decisions for the family? Occupation in native country Present Occupation Education? RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 23 Discharge Information Who do you live with?
Number of children at home and ages:
Who will take care of you after discharge?
Who will provide transportation upon discharge?
Where will you go at discharge? Home Home w/Home Health - Name of Agency Nursing Home - Name of Nursing Home Other Medical equipment used at home? No Yes If yes, What type? Does patient use specialty bed? No Yes If yes, What type? Anticipated needs at discharge: Equipment (explain): Supplies (explain): Transportation (explain): Safety Concerns: (explain):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 24 Nurses Notes: Include notes that cover the entire shift(s) you cared for patient
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 25 Patients Primary and Secondary Diagnoses Definition and Pathophysiology of Primary and Secondary Diagnoses: Primary Diagnosis:
Secondary Diagnoses:
Common Treatments and Medical Interventions for Primary and Secondary Diagnoses: Primary Diagnosis:
Secondary Diagnoses:
Focused nursing assessment for Primary and Secondary Diagnoses to include: Primary Diagnosis:
Secondary Diagnoses:
Additional information important to patient care:
SOURCES (APA Format):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 26 Medications and Parental Therapy Solution Infusing Rate of Infusion Nursing Interventions
Medication Generic/Trade Name Dosage Route Freq Indications Specific to your patient Adverse Reactions Nursing Interventions - Specific to your patient
SOURCES (APA Format):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 27 Lab Studies LAB STUDY
NORMAL VALUE PATIENT VALUE Indicate if value is: High, Low, Normal SIGNIFICANCE What does the abnormal value mean to your specific patient? NURSING RESPONSIBILITIES Identify responsibilities, specific to your patient, for all lab studies: Prior to the lab study and after any abnormal value Admission Most Recent
SOURCES (APA Format):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 28 Diagnostic Exams related to Patient Assessment Diagnostic Exam(s) Nursing Responsibilities - Specific to your patient Results (in your own words) Implications for Patient - Specific to your patient
SOURCES (APA Format):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 29 Problem List List and Prioritize a minimum of 5 problems. Problem List may include only one Risk for NANDA statement. Priority # Date Problem in NANDA form Nursing Diagnosis R/T Etiology AEB Subjective and Objective Data
SOURCES (APA Format):
RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 30 Diagnosis by Nanda Type your answers in the space provided. The boxes will expand as you type. Sources (APA Format):
DIAGNOSIS BY NANDA PLAN/GOAL INTERVENTION (Indicate I or C) RATIONALE (Paraphrase information and Include Reference Page #) EVALUATION NANDA #1:
SHORT TERM GOAL #1 Patient will
1. 1. 1. SHORT TERM GOAL #2 Patient will
2. 2. 2. AEB SHORT TERM GOAL #3 Patient will
3. 3. 3. Subjective Data:
SHORT TERM GOAL #4 Patient will
4. 4. 4. Objective Data:
LONG TERM GOAL#1 Patient will
5. 5. 5. RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 31 Type your answers in the space provided. The boxes will expand as you type. Sources (APA Format):
DIAGNOSIS BY NANDA PLAN/GOAL INTERVENTION (Indicate I or C) RATIONALE (Paraphrase information and Include Reference Page #) EVALUATION NANDA #2:
SHORT TERM GOAL #1 Patient will
1. 1. 1. SHORT TERM GOAL #2 Patient will
2. 2. 2. AEB SHORT TERM GOAL #3 Patient will
3. 3. 3. Subjective Data:
SHORT TERM GOAL #4 Patient will
4. 4. 4. Objective Data:
LONG TERM GOAL#1 Patient will
5. 5. 5. RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 32 Type your answers in the spaces provided. The boxes will expand as you type. Sources (APA Format):
DIAGNOSIS BY NANDA PLAN/GOAL INTERVENTION (Indicate I or C) RATIONALE (Paraphrase information and Include Reference Page #) EVALUATION NANDA #3:
SHORT TERM GOAL #1 Patient will
1. 1. 1. SHORT TERM GOAL #2 Patient will
2. 2. 2. AEB SHORT TERM GOAL #3 Patient will
3. 3. 3. Subjective Data:
SHORT TERM GOAL #4 Patient will
4. 4. 4. Objective Data:
LONG TERM GOAL#1 Patient will
5. 5. 5. RNSG 2361 Clinical
2014 Lamar State College Port Arthur Page 33 Clinical Log Clinical Site: Student Name: Date: Patient Description Current Medical Diagnoses: Focused Physical Assessment Narrative Statement: Psychosocial Assessment Narrative Statement: Student's Learning Learning Gained During This Clinical Experience: Learning Needs Related To This Clinical Experience: Problems Encountered/Alternative Approaches Problems Encountered During Clinical/Alternative Approaches: Students Feelings/Perceptions Students Feelings/Perceptions Following This Clinical Experience: