Solved by verified expert:School of Health Professions, Science and WellnessDepartment of NursingDaily Clinical logSpring 2017Course: __________________________________________________________________________Student: _________________________________ Date: _____________________________Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________Date of Admission: ________________ Date of Care: _____________________________Present Medical Diagnoses: ____________________________________________________Present Surgery (if applicable): _____________________ Date of Surgery: ______________Allergies: __________________________ Code Status: ________________________Vital Signs T_____________ P_____________ R____________ BP______________ SPO2___________General AppearancePsychiatricHEENTNeckBreastsLymph NodesPulmonaryCardiovascularSkinNailsAbdomenGenitourinaryPelvicRectalExtremitiesMusculoskeletalNeurological (DTR’s, reflex grading, cranial nerve evaluation)IncisionsDrainsDiet/NutritionIVsIntake and OutputFall Risk Assessment (include score)Pressure Ulcer Risk Assessment (include score)Pain assessment (include reassessment)TimeScoreInterventionReassessment TimeScoreDiagnostic Assessments – Important EKGs, X-Rays, and LabsLab/Other TestPatient valuesInferenceMedications Administered:MedicationsDose/Brand name/Generic nameIndication of useAdverse Effect/Side effectNursing ImplicationsTreatments and ProceduresDay & TimesRationaleNursing Interventions:Assessment FindingsNursing DiagnosisOutcomeNursing InterventionsEvaluationsReflections of the day on meeting course objectives:
