CHAM BE RLAI N COL LEG E

of

NU RSIN G

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu
Please visit chamberlain.edu/locations for location specific address, phone and fax information.

CLINICAL I-SBAR

Introduce Yourself

Situation

Background

Your Name:
Your Title:
Reason for being here:
Patient:
Age:
Gender:
Height/Weight:
Allergies:
Code Status:
Privacy Code:
Time:

Attending Physician:

Past Medical History:

Current Medications:

Patient Chief Complaint:

Social History:

Vital Signs:

B/P

HR

RR

TEMP

SP02

PAIN

Assessment
Falls risk:
IV Site:
Isolation

Accu check:
IV Fluids:

Isolation Precautions: N Y

Contact

Air Droplet

Respiratory
Cardiovascular
Neurological
GI/GU I & O
Integumentary
Psychological Family-Support
Safety
Labs/Test

Teaching needed:
Abnormal:
Pending:

Request/Recommendation
Hand off Report to:

From:

Comprehensive consumer information is available at chamberlain.edu/studentconsumerinfo.

FOR ARLINGTON CAMPUS STUDENTS:
Chamberlain College of Nursing, 2450 Crystal Drive, Arlington, VA 22202 is certified to operate by the State Council of Higher Education for Virginia, 101 N. 14th Street, 10th Floor, James Monroe Building, Richmond, VA 23219, 804.225.2600.
Chamberlain College of Nursing has full approval from the Virginia Board of Nursing, Perimeter Center, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, 804.367.4515.
12-000000

2015 Chamberlain College of Nursing LLC. All rights reserved.

0815pflcp

CHAM BE RLAI N C OLLEG E

of

NURSIN G

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

HEAD-TO-TOE ASSESSMENT

The following head-to-toe assessment is what students are required to perform on all patients. Specialty assessments will be based on course and
course instructor.
1. Assess level of consciousness (LOC) and orientation to person, place, and time, mood, affect, developmental level,
level of assistance required for ADLs
2. T-P-R B/P, pain level (0-10 scale) & location, pulse oximetry
3. Assess the head:
a. General survey for gross abnormalities, symmetry of face.
b. Color if sclera, conjunctiva dryness of eyes
c. PERRLA
d. Oral cavity: odor, lips, teeth , gums, buccal cavity, tongue protrudes midline, swallowing
e. Presence of hearing aids and/or glasses
4. Throughout assessment continually observe and note condition of hair, skin (turgor), and nails-ongoing monitoring of
skin condition including Braden Scale
5. Asses and compare bilateral upper extremities for:
a. Hand grasps for equality and muscle strength
b. Temperature and color
c. Brachial & Radial pulses
d. Capillary refill
6. Assess apical pulse:
a. Auscultate heart sounds(S1, S2) at five valve points including point of maximal intensity (PMI)
b. Listen for one minute, noting rate, rhythm and regularity
7. Assess Lungs
a. Observe rise and fall of chest: assess for chest expansion & use of accessory muscles
b. Auscultate breath sounds
i. Assess anterior chest in 4 sites and 2 lateral sites ii.
Assess posterior chest in 6 sites and 2 lateral sites

8. Assess Abdomen:
a. Inspect abdomen for contour, lesions, scars
b. Auscultate bowel sounds in all four quadrants
c. Palpate abdomen for firmness, tenderness, and suprapubic region for bladder distention
d. Assess last BM and consistency
e. Assess urinary output
9. Assess and compare bilateral lower extremities for (CMS):
a. Movement and muscle strength, sensation, cap refill
b. Temperature and color, hair distribution
c. Dorsalis pedis (pedal) and posterior tibial pulses
d. Assess for DVT, swelling, measures
e. Edema
10. Monitor diet and nutritional intake
11. Check equipment:
a. IV Solution, rate, assess site for s/s inflammation
b. O2 Setting and device, assess skin
c. Drains (including urinary catheter, feeding tubes etc.)
12. Survey environment for safety concerns-ongoing, fall risk
At completion, place call light within reach, assure pt. is comfortable and safe & perform hand hygiene
Additional information:
Student should report any abnormal findings to instructor immediately.
Assessments should be observed a minimum of twice a session. These should be documented and feedback given to student.
Full assessments are required on all clients unless the type of facility does not allow for such.
Students should perform manual blood pressures and all other vital signs. This is a skill that must be practiced as often as possible.

CHAM BE RLAI N C OLLEG E

of

NURSIN G

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

PATIENT ASSESSMENT AND CARE PLAN

Student:
Client Initials:

Date of Care:
Room #

DOB:

Gender:

Admitted to facility Date:

Allergies:

Resuscitation Status :

Reason for Admission:

Social: M W S D Significant other, Next of Kin or POA for Healthcare:

Occupation or former occupation:

Primary Healthcare Provider(s):

Medical Diagnoses:

Surgeries/Procedures and Dates:

Consultants/Specialists

Age:

Current Physician/Healthcare Provider Orders (Prescriptions for Care)

Item Type

This Residents Orders

Rationale

Diet
Activity
I/O
VS
Accu-Cheks
Foley
NG
PEG/PEJ tube
Wound Care / Dressing Change
Respiratory Treatments
Tracheostomy
Suctioning
Chest Tube
Special Equipment
Lab orders
Other
Rehab Services

Activity or Treatment Plan & Schedule

Rationale

Physical Therapy
Speech Therapy
Occupational Therapy
IV Access:
Type

Site:

Last Dressing Change

Last Tubing Change:

Reason for IV access

IV fluids and meds

Most recent Imaging Findings: (CXR? CT? MRI?)

Type of Imaging
(X-Ray, CT, MRI, etc)

Body Area Imaged

Reason for testing and results of test

Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date

Lab Test

Results

Norms

Other recent, significant procedures or tests (EKG, etc)

Date

Test

Reason for testing and results of test

Comments

Residents Developmental Stage according to Erikson:

Your assessment of this residents response to the opportunities and potential conflicts of this stage:

List one of the resources you used to learn more about this residents diagnoses:

Based on the information on these pages and your assessment of this resident, what is your FIRST or PRIORITY concern?
(What worries you the most about this resident?)

MEDICATIONS
Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

MEDICATIONS
Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Brand Name and Generic Name

Normal Dosage Ranges

Pharmacotherapeutic Class

Dosage Ordered

Why is patient receiving this med? (Can list

related diagnosis, symptom, or need)

Route and Frequency

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

Contraindications

Adverse Reactions

Nursing Considerations and Teaching

NURSES NOTES
For this clinical, we are having you write out your assessment findings in the form of a narrative nurses note. See samples of assessments on the next page.
Take the Physical Assessment Worksheet into the residents room to take notes during your assessment.
Date / Time

Apical HR

Resp

BP

height

weight

SAMPLE NARRATIVE NOTES

Date / Time
12/22/2010
14:00

T
98.6

Apical HR
72

Resp
16

BP
128/62

height
55

weight
185 lbs.

Alert and oriented x 3. Recent and remote memory intact. Motor and sensory functions grossly intact. No weakness or
paralysis. No involuntary movement or abnormal posture. Appropriate mood and affect.
Skin pink, warm, dry, free of lesions. Elastic turgor. Hair and nails unremarkable.
Pupils equal, reactive to light and accommodation. Oral mucosa moist, pink. Dentition intact. Oropharynx clear without
erythema or exudate.
Lung fields clear bilaterally to auscultation. Respirations non-labored.
Apical pulse regular (rate) and rhythm. Carotid, radial, and pedal pulses palpable and equal bilaterally. Cap refill < 3 sec.
Bowel sounds active x 4. Abd soft, non-distended, non-tender. Last BM this morning, large, soft- formed,
Extremities c equal strength bilaterally, unlimited ROM. No tenderness, swelling or joint deformities noted. Denies
numbness or tingling to extremities. No peripheral edema noted.
SAMPLE Narrative Note with Numerous Abnormal Findings
Resident sitting in wheelchair. Pressure reduction cushion in place. No foot rests as resident propels self in wheelchair.
Speech soft but clear. Occasional stutters. Alert, oriented to self, unaware of date, unable to name location. Can recall
name of daughter. Cannot remember what she ate for breakfast. Hx of CVA with R hemiparesis; moves R foot well
enough to propel chair; R hand is slightly contracted. Grip stronger on L than R. Resident leans very slightly to R. Eye
prosthesis on R; L pupil is reactive to light and accommodation.
Skin pale, warm, very dry, with flaking. Skin tear noted R forearm, Band-Aid in place. No other breaks in skin integrity, no
redness. Turgor fair. Scar over L chest wall at old mastectomy site. No masses palpated over scar. Hair thin. Toenails
thick and yellow. Sees podiatrist monthly.
Oral mucosa moist, pink. Hard white lesion noted at R base of tongue. Referred to charge nurse T. Sabaj for follow up.
Upper and lower dentures in place with oral debris noted. Oral care provided. Oropharynx clear without erythema or
exudate.
Lung fields auscultated. Crackles at bilateral bases. Cleared with cough. Lung fields otherwise clear to auscultation.
Apical pulse 68 with occasional skipped beats. Resident has history of PVCs. 3 skipped beats per minute. Pt in no
distress. Carotid, radial, and pedal pulses palpable and equal bilaterally. Cap refill < 3 sec. Slight mottling of toes in
dependent position.
Bowel sounds active x 4. Abd soft, non-distended, non-tender. Last BM 2 days ago.
Moderate ROM limitations on R side. Cannot raise R arm to shoulder level. Discussed with Charge Nurse, and referral
made to Rehab Services for screening. No tenderness, swelling or joint deformities. Denies numbness or tingling to
extremities. No peripheral edema noted.

PHYSICAL ASSESSMENT WORKSHEET

Use this sheet for jotting down your assessment findings. Follow guidelines from NR 302/NR 304 head-to-toe sheet.
Routine Findings

Patient Variations/Abnormals

Skin:

Head and neck:

Breasts:
Deferred

Respiratory:

Cardiovascular:

Abdomen:
Bowel continence?

Last BM?

Bowel Plan?

Neurological :

Musculoskeletal:

Genitourinary:
Urinary continence?

Toileting plan?

Pelvic:
Deferred

Rectal:
Deferred

CHAM BERL AI N CO LL EG E

of

NUR SI N G

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

PATIENT ASSESSMENT AND CARE PLAN

Nursing Care Plan
Patient Initials, Age, Gender:

Student Name And Date:

Nursing Diagnosis
or Collaborative Problem:
Related to:

As Evidenced By:

Desired Patient Outcomes

Make sure they are specific, measurable, realistic and have a time frame stated.

Nursing Interventions

Patient will:
1
2
3

Patient will:

4
5
6

Comprehensive consumer information is available at chamberlain.edu/studentconsumerinfo.

FOR ARLINGTON CAMPUS STUDENTS:
Chamberlain College of Nursing, 2450 Crystal Drive, Arlington, VA 22202 is certified to operate by the State Council of Higher Education for Virginia, 101 N. 14th Street, 10th Floor, James Monroe Building, Richmond, VA 23219, 804.225.2600.
Chamberlain College of Nursing has full approval from the Virginia Board of Nursing, Perimeter Center, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, 804.367.4515.
12-000000

2015 Chamberlain College of Nursing LLC. All rights reserved.

0815pflcp

Nursing Care Plan

Patient Initials, Age, Gender:

Student Name And Date:

Nursing Diagnosis
or Collaborative Problem:
Related to:

As Evidenced By:

Desired Patient Outcomes

Make sure they are specific, measurable, realistic and have a time frame stated.

Nursing Interventions

Patient will:
1
2
3

Patient will:

4
5
6

Nursing Care Plan

Patient Initials, Age, Gender:

Student Name And Date:

Nursing Diagnosis
or Collaborative Problem:
Related to:

As Evidenced By:

Desired Patient Outcomes

Make sure they are specific, measurable, realistic and have a time frame stated.

Nursing Interventions

Patient will:
1
2
3

Patient will:

4
5
6

CH AMB ER LA I N C O LLEG E o f NUR S IN G

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu
RUBRIC for Grading Patient Assessment & Care Plan
Student:

Clinical Date:
Section

Grading Criteria

Points Possible

Client Assessment

Patient Demographics, Diagnoses, Surgeries, Orders, Rehab, IV,

Imaging and Lab are fully and correctly completed
Developmental stage & potential conflict correctly identified
Priority concern identified & appropriate
Used appropriate resource

20

Medication Cards

Medication Trade & Generic name, Pharmacological Classification, Normal

Dosage Range, dose ordered, route & frequency, contraindications & Adverse
Effects/Reactions identified appropriately
Nursing Considerations & Teaching appropriate for this patient
Legibly written or typed clearly

10

Head-to-toe assessment documented clearly and accurately

Nurses Note is in logical order, using appropriate language & clearly understood.
Abnormal findings have a follow up note

10

Nursing plan of care completed

Total of three appropriate Nursing Diagnosis (ND) or Collaborative
Problems (CP) identified.
ND or CP properly formatted with Related to statement correctly formatted
and appropriate for this patient.
As evidenced by is appropriately stated and correct for this patient
Outcomes specific, measurable, timed
Interventions are logical and appropriate for this patient

10

Head-to-Toe Assessment

Patient Care Plan

Total points possible/Total points earned

12-000000

2015 Chamberlain College of Nursing LLC. All rights reserved.

Site:
Comments, Kudos,
Things to Improve for Next Time

Points Earned

50

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