Weekly Concept Focus

• Mobility or Safety
• Elimination
• Oxygenation: Gas Exchange
• Thermoregulation or fluid and electrolytes
• Inflammation/infection
• Tissue Integrity
• Pain

Date:

Student name:

Clinical Site/Unit:

Clinical Site Instructor:

Clinical Site Mentor:

Overweight/underweight:

Allergies:

Marital Status:

Religion:

Cultural Background:

Primary Language:

Code status:

Diet/Nutrition:

Activity:

Treatments:

IV/Tubes/Ostomies:

Interdisciplinary Cares (OT/PT/RT):

Dressings/Wounds: (type & location)

Oxygen: (delivery method & amount)

Dialysis:

Admitting Medical Diagnosis(s):
Primary (if different than Admitting)
Secondary (Do not include History Of):

Medication Data Sheet

Scheduled Medications that your patient is currently taking.

Drug Name and Classification	Expected action & indication for use	Side Effects/ Adverse Reactions	Medication/Food Interactions	Nursing Administration Special Instructions & Assessments	Client Education & Evaluation of Medication Effectiveness e.g. Pain Scale

Daily “Brains”, to be completed during clinical day.Begin your day with a plan and change/make notes as needed.You may print and use this template or create your own.

Room #:

Diet:

Ambulation:

IV fluids:

Allergies:

	Medications	Treatments	Nursing care/interventions	Vital Signs
0700
0800
0900
1000
1100
1200
1300

ASSESSMENT SUMMARY: Complete in narrative form based on the form filled out during clinical day.

Body System
Vital Signs and Pain Level:
Sensory:
Neurological:
Respiratory:
Cardiac:
Integument:
Gastrointestinal:
Musculoskeletal:
Renal:
Endocrine:
Immune and Hematologic:
Psychosocial/ Sociocultural / Spiritual:

Patient education: (e.g. medication, possible complications associated with the patient, nutrition, activity)Complete in a narrative format exactly how you would educate the patient.Include 7 narrated sentences.

Outcome: Critical Thinking: Self assessment:

Self reflect on how your clinical experience correlates with what you learned in this week’s module.Objectives are located in the course under each module and are helpful in completing this section.

Outcome: Caring

Identify one example from your clinical day in which you observed, participated in, or provided some aspect of caring for the provision of psychosocial and/or cultural diversity needs. How did you inspire or make a difference in your patients life today?

References (at least 3 in APA format)