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What information to gather from my patient before clinical rotation?

Posted
Garlio Garlio (New) New

Hello I am a 5th semester student barely starting clinicals. I am so excited and nervous at the same time. I have to develop a nursing care plan before actually making a complete assessment on my patient. I have to get all the information from the patient's chart and record one day before I meet my patient face to face. I was wondering what advice could you give me in order to develop a great care plan. I know that I have to gather information like medications, medical diagnosis, lab tests results, allergies, age, gender, etc.. The much info the better, I would really appreciate some piece of advice! Thanks in advance.

Prioritize using the ABCs (airway, breathing, circulation). Check their labs, I&Os, vitals, read the H&P which should contain a head to toe assessment, discharge goals, and so forth. Whatever you do, don't put down Ineffective coping as your main nursing diagnosis lol.