The Ultimate Guide to Transitioning from Nursing Classroom to Clinicals

Welcome to the thrilling adventure of nursing clinical rotations! This is where all that classroom knowledge finally gets to shine in real-world settings. We’re here to help you tackle your clinical rotations with confidence and a smile with this guide. From top-notch prep tips to savvy stress-busting strategies, we’ve got your back!

By focusing on the importance of preparation, we’ll make sure you’re ready to ace each rotation. So, let’s dive in and make the most of this exciting chapter in your nursing journey!

Navigating the Clinical Education Journey

Your clinical education starts with a mix of classroom learning and hands-on practice. Typically, you’ll attend lectures where you’ll get a thorough overview of clinical skills, common conditions and treatments, and nursing care plans. Then, it’s off to the lab to practice these skills on mannequins and get comfortable with the equipment. Simulation labs are also integrated into each clinical course, providing high-tech, real-life scenarios to hone your skills in a safe environment before hitting the clinical floor.

Differences Between Classroom Learning and Clinical Practice

In the classroom, learning is primarily theoretical. You’re absorbing information from textbooks, lectures, and discussions. The environment is controlled, and you have the luxury of time to think through problems and ask questions. You’re often working individually or in small groups, and the stakes are relatively low.

Clinical practice is a whole different ball game because you apply that theoretical knowledge to real-world settings. The environment is dynamic and can be unpredictable. You’re working with real patients with real needs, and the stakes are much higher. You’ll need to be able to think on your feet, make quick decisions, and adapt to changing situations. It’s a hands-on, immersive experience that can be both exhilarating and daunting.

General Advice for Clinical Rotations

Roles in Clinicals

Get clarity on the roles of a clinical instructor and a preceptor and how they differ. Your clinical instructor is responsible for your overall education and evaluation and likely signs off on your documentation and medication administration (depending on the school and clinical site). Your preceptor is generally a practicing nurse who provides support during your clinical shifts and is the primary nurse for the patients.

Determining Evaluation Criteria

Make sure you understand how you’ll be evaluated in a clinical setting. Evaluations typically include assessments of your clinical judgment, ability to provide holistic care, communication skills, and professionalism. They usually include a self-evaluation at midterm and final and an assessment by your instructor within the same periods. It’s best to have your evaluations printed out, but most evaluations typically include these elements.

Understand Your Scope of Practice

The scope of what you can and cannot do in a clinical setting often varies from clinical site to clinical site, depending on policy. Always ask for clarification from your clinical instructor or preceptor if you’re unsure about your scope of practice.

Get Comfortable with Clinical Paperwork

Be prepared to complete various types of clinical paperwork, such as patient care plans, notes, and data collection forms. Familiarize yourself with the documentation requirements of your clinical site.

Proactively Build Relationships

Establish successful relationships with the unit staff. Show respect, be a team player, and seek learning opportunities from experienced nurses and other healthcare professionals.

Clinical Skills vs Holistic Care

Place less emphasis on mastering clinical “skills” and more on providing holistic care and making sound clinical judgments. This approach will help you become a well-rounded nurse.

Use the One-Minute Patient Checkup

Before diving into specific clinical rotations, it’s essential to master the “one-minute patient checkup.” Check the appendix at the end of this guide to get help with gauging a patient’s stability and identifying any immediate concerns. Use it to guide you through a thorough patient checkup and help you organize your clinical day.

And don’t forget to focus on your ABCDEs!

ABCDEs

The ABCDE approach is a systematic method for assessing and prioritizing what you need to check first. Use it to evaluate your patient’s condition quickly:

• Airway: Ensure the patient’s airway is clear. Note if they’re able to speak clearly. Look for any obstructions and listen for sounds indicating a blocked airway.

• Breathing: Check the patient’s breathing, respiratory rate, rhythm, and effort. Look for signs of respiratory distress, like labored or shallow breathing.
• Circulation: Check the patient’s circulation. Assess the pulse rate, rhythm, and strength. Look for signs of poor perfusion, such as pale or cyanotic skin.
• Disability: Evaluate the patient’s level of consciousness and neurological status using the AVPU scale (Alert, Verbal response, Pain response, Unresponsive) to check for responsiveness.
• Exposure: Expose the patient’s body, as needed, to look for signs of trauma, bleeding, rashes, or other abnormalities. Ensure the patient stays warm and comfortable.

Things to Note in a Patient’s Room

When you first enter the patient’s room, take a moment to observe the environment, and then:

• Introduce Yourself: Begin by introducing yourself to the patient. Explain who you are and what you will be doing.
• Verify the Patient’s Identity: Confirm the patient’s identity using two identifiers (e.g., name and date of birth).
• Determine the Patient’s Overall Condition: Observe their overall appearance and position in bed.
• Check Medical Equipment: Take a look at any medical equipment currently in use, such as IV pumps, oxygen delivery systems, and urinary catheters and confirm they’re functioning properly.
• Monitor Readings: Observe the readings on any monitors (e.g., heart rate, oxygen saturation, blood pressure).
• Assess the Environment: Ensure the call light is within reach and the bed rails are adjusted for safety. Note any hazards or obstacles in the room.

Taking Vital Signs

After noting your initial observations, check the patient’s vital signs:

• Temperature 
• Pulse 
• Blood pressure
• Respiratory rate
• Oxygen saturation (Pulse oximetry)

Pain Management

Determine patient pain levels.

• Ask About Pain: Use a pain scale (e.g., 0-10) to determine their current pain level.
• Location of Pain: Ask the patient to describe the location, nature, and duration of their pain.

Ask About PRN Medications

Ask if the patient requires any as-needed (PRN) medications:

• Inquire: Ask the patient if they are experiencing any symptoms requiring PRN medications (e.g., pain, nausea).
• Administer: If PRN medications are needed, follow the appropriate steps to administer them, and document accordingly.

General Appearance

Evaluate the patient’s general appearance:

• Skin Color: Note if the skin is pale, flushed, or cyanotic.
• Breathing Effort: Observe if their breathing is labored or shallow.

Communicating with Patients

Throughout the assessment, maintain clear and compassionate communication:

• Explain Your Actions: Inform the patient of each step you’re taking and why it’s necessary.
• Provide Reassurance: Offer reassurance and answer any questions the patient may have.
• Engage the Patient: Encourage the patient to share concerns or symptoms they’re experiencing.

Important Points to Remember:

• Prioritize Critical Findings: If you identify any abnormal values, investigate further and take necessary actions immediately.
• Adapt to the Situation: The specific elements of a one-minute patient checkup may vary, depending on the patient’s condition and current clinical situation.
• Communication is Key: Inform your healthcare team of any significant changes observed during the assessment.

How to Think Like a Nurse

There are a few ways to enhance clinical thinking in the clinical arena; which model you use depends on your nursing program and/or your personal preference. RNs in the US and LPNs in Canada often find using the nursing process, ADPIE, helpful. ADPIE helps you assess (A) the patient, create a list of problems along with a nursing diagnosis (D) that enables you to plan (P) and implement (I) a care plan that’s evaluated (E) to track outcomes. Similarly, US LPNs utilize the Clinical Problem-Solving Process (data collection, planning, implementation, and evaluation).

Another method for making clinical decisions is the Clinical Judgment Model (CJM). With CJM, start by recognizing cues, then analyze them, develop a list of priorities and hypotheses, and move on to generating solutions so you can take action and evaluate the outcomes of your actions. Let’s look at a brief overview of each one!

Clinical Judgment Model

The Clinical Judgment Model is a framework that helps nurses make informed decisions based on clinical reasoning.

1. Recognize Cues: Identify relevant information from patient data.
2. Analyze Cues: Interpret the cues to understand the patient’s condition.
3. Prioritize Hypotheses: Determine the most likely explanations for the patient’s condition.
4. Generate Solutions: Develop interventions to address the prioritized hypotheses.
5. Take Action: Implement the interventions.
6. Evaluate Outcomes: Evaluate the results of the interventions and adjust the plan as necessary.

ADPIE: The Nursing Process

Primarily used by RNs in the US and LPNs/RNs in Canada, ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation, providing a systematic approach to patient care.

1. Assessment: Collect comprehensive data relevant to the patient’s health.
2. Diagnosis: Analyze the assessment data to determine the issues.
3. Planning: Develop a plan with interventions to address the diagnoses.
4. Implementation: Execute the planned interventions.
5. Evaluation: Assess the effectiveness of the interventions and modify the plan as needed.

Clinical Skills: Mastering the Essentials

Clinical rotations are where you’ll hone the practical skills vital to excellent patient care. Each clinical rotation will present unique challenges and opportunities to develop your expertise. Depending on your program (LPN or RN), you’ll likely collect data, administer medications, or assist with complex procedures. Mastering these skills is crucial to your success as a nursing student and future nurse.

To help you along the way, we recommend printing or downloading the Osmosis badge cards, packed with easy-to-remember clinical pearls that serve as handy references during your rotations. Keep them in your badge holder to refresh your memory about essential skills and tips.

Now, let’s dive into the key skills you’ll be developing in each clinical rotation:

• Basic Nursing Procedures: Mastering basic nursing procedures, like taking vital signs, administering medications, and performing wound care, is fundamental. Practice these skills regularly to build proficiency and confidence. Don’t hesitate to ask for guidance or additional practice opportunities if needed.
• Time Management: Effective time management skills are crucial in clinical settings to ensure you can prioritize tasks, manage your workload, and deliver patient care efficiently. Create a daily plan, set realistic goals, and use tools like checklists to stay organized. Remember to be flexible and be ready to adapt to changing priorities as needed.
• Patient Exam: Conducting a thorough patient exam is a fundamental clinical skill. This process includes collecting detailed information about the patient’s health, recognizing potential concerns, and determining the best course of action. Strengthen your clinical abilities by performing comprehensive head-to-toe exams, reviewing medical histories, and applying critical thinking to detect any irregularities.
• Technical Skills: In addition to basic procedures, you’ll need to develop technical skills specific to your clinical area. Many of the skills you develop will depend on the region where you practice, and the scope of practice allowed by your regulatory body. It may include maintaining IVs and catheters if you’re an LPN student or starting IVs and inserting catheters if you’re an RN student. Take advantage of simulation labs and hands-on training to practice these skills in a controlled environment.

Preparing for Clinical Rotations

Expectations and Responsibilities

Preparation for clinical rotations starts well before your first day. Understanding the expectations and responsibilities of each rotation will help you feel more confident and prepared.

• Understand the Rotation: Familiarize yourself with each rotation’s specific focus and objectives. Knowing what to expect can help you prepare accordingly.
• Review Policies and Procedures: Each clinical site has different policies and procedures. Take the time to review these guidelines to ensure you’re in compliance with them.
• Gather Necessary Supplies: Make sure you have all the necessary supplies, including your stethoscope, penlight, notepad, pens, and a clean uniform. Having everything ready reduces last-minute stress.

Before Your First Day

Preparing before your first day will help you start your rotation on the right foot!

• Plan Your Route: Do you know how to get to your clinical site, where to park, what trains or buses to catch, and how long the commute will take? Arriving early can help you start your day calmly. Also consider making the commute at a similar time before you start your rotation to determine how long it takes to get there.
• Attend Orientation: Orientations are an excellent opportunity to familiarize yourself with the environment and ask any questions you may have. If your school or clinical site offers an orientation, make sure to attend!
• Review Key Concepts: Brush up on relevant concepts and skills to feel more confident and prepared. Use resources like Osmosis to review disease processes, procedures, and essential nursing skills.

Practice Self-Care and Resilience

Taking care of yourself is crucial for your success as a nursing student. Prioritize self-care, seek support when needed, and utilize resiliency practices in the face of challenges. Remember, becoming a nurse is a marathon, not a sprint!

Find Your Path

Your clinical rotations are an excellent opportunity to explore different specialties and find your passion. Seek out mentors, set goals, and continuously seek prospects for growth and development. Your journey is unique, and finding the right path is essential.

Treat your clinical rotations like a job interview (where they’re considering you, and you’re considering them). Though your primary goal is to learn and become a safe, caring, and effective nurse, the impression you leave at your clinical sites can impact your future job prospects.

The Path through Clinical Rotations: Building Your Nursing Expertise

Your clinical rotations generally kick off with applying the fundamentals of nursing, where you learn basic patient care. Then, it’s on to medical-surgical nursing (med-surg), where you dive into more complex care scenarios. Depending on your program, you may rotate through pediatrics and obstetrics (sometimes combined), working with children and expecting mothers. Then comes psychiatric nursing, where you’ll focus on mental health care. You’ll experience more complex cases and populations as you advance in your training.

Keep in mind that the order of these rotations may vary depending on your program, but each step builds your skills and boosts your confidence, preparing you for a successful nursing career!

Fundamentals of Nursing

Introduction to Fundamentals of Nursing

The Fundamentals of Nursing rotation is often the first clinical experience for nursing students. It is the foundation for all your rotations, focusing on basic patient care skills and essential nursing principles. This rotation typically takes place in long-term care facilities, where you’ll learn to provide comprehensive care to patients with chronic conditions.

Essential Skills in Fundamentals of Nursing

• Basic Patient Care: Assisting with activities of daily living (ADLs) such as bathing, dressing, and feeding.
• Vital Signs Monitoring: Regularly checking and recording temperature, pulse, blood pressure, and respiratory rate.
• Hygiene Assistance: Providing oral care, skin care, and hair care to maintain patient hygiene.
• Patient Transfers: Safely moving patients from bed to chair or wheelchair, and vice versa.
• Feeding Assistance: Helping patients with meals, ensuring adequate nutrition and hydration.
• Use of Assistive Devices: Familiarizing yourself with walkers, wheelchairs, and other mobility aids.

Resources for Fundamentals of Nursing

Brushing up on your physical exam skills to excel in this rotation is essential. We suggest exploring our comprehensive guide on the Fundamentals of Nursing for recommendations.

Essential Skills in Adult Health/Medical-Surgical Nursing

During rotations, you’ll be practicing:

• Conducting Patient Exams: Using thorough assessments to gather data on patient conditions.
• Medication Administration: Delivering medications safely and accurately, including oral, intramuscular, and subcutaneous routes.
• Wound Care: Assessing and cleaning wounds, changing dressings.
• Care Planning: Developing or following a set plan of care and implementing individualized care plans based on patient needs.
• Monitoring Vital Signs: Continuously monitoring and interpreting vital signs to detect changes in patient status.
• Patient Education Planning: Reinforce teaching for patients and families about disease processes, treatments, and self-care.

Tools for Adult Care and Older Medical-Surgical Nursing

• Osmosis Med-Surg Nursing Videos: Improve your understanding of medical-surgical nursing concepts with Osmosis.
• Drug Dosing Tools: Use reliable apps such as Epocrates or Medscape to ensure accurate medication dosing and to stay informed about drug interactions and side effects.

Pediatrics

Introduction to Pediatrics and Family Care

Your pediatrics rotation is an exciting and rewarding experience, allowing you to work with children and their families. This rotation typically takes place in hospitals or outpatient clinics, where you’ll learn to address the unique healthcare needs of pediatric patients.

Essential Skills in Pediatrics

• Pediatric Exams: Conducting age-appropriate assessments, including growth and development monitoring.
• Medication Administration: Administering medications with attention to pediatric dosing and delivery methods.
• Family-Centered Care: Engaging families in the care process and ensuring they understand what to expect concerning their child’s health, milestones, and development.
• Vaccination Administration: Safely administering vaccines and educating families about immunization schedules.
• Growth and Development Monitoring: Tracking developmental milestones and identifying any concerns.

Resources for Pediatrics

The American Academy of Pediatrics is an excellent resource to learn more about this specialty.

Obstetrics (OB)

Introduction to Obstetrics

Depending on your state and program, you may have an obstetrics (OB) rotation, which involves caring for pregnant patients during pregnancy, labor, delivery, and the postpartum period. This rotation typically takes place in hospitals, where you support women through one of the most momentous events in their lives.

Essential Skills in Obstetrics

• Prenatal Care: Conducting prenatal exams, including fetal monitoring and maternal health evaluations.
• Labor and Delivery Support: Assisting with labor and delivery, including monitoring contractions, providing comfort measures, and supporting the delivery process.
• Postpartum Care: Caring for mothers and newborns after delivery, including breastfeeding support and postpartum assessments.
• Newborn Assessments: Conducting initial and ongoing assessments of newborns, including Apgar scoring and monitoring for any complications.

Resources for Obstetrics

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) offers a wealth of resources for OB nurses.

Psychiatric Nursing (Psych)

Introduction to Psychiatric Nursing

Your psychiatric nursing rotation, often referred to as psych, involves caring for patients with mental health conditions. This rotation typically takes place in hospitals or community settings, where you’ll learn to provide compassionate and therapeutic care for individuals experiencing psychiatric crises.

Essential Skills in Psychiatric Nursing

• Mental Health Exam: Conducting comprehensive psychiatric assessments to determine patient needs and develop care plans.
• Therapeutic Communication: Building rapport and using therapeutic communication techniques to support patients.
• Managing Medications: Administering psychiatric medications and monitoring for side effects.
• Patient Education Plan: Reinforcing the teaching plan for patients and families about mental health conditions, treatments, and coping strategies.

Resources for Psychiatric Nursing

• American Psychiatric Nurses Association (APNA) offers resources and support for psychiatric nursing practice.

Coping Mechanisms for Stress and Anxiety

As you learn the essential skills and resources for each clinical rotation, it’s important to talk about the challenges of managing stress and anxiety during this period of your nursing career. Clinical rotations can be demanding, but with the right coping mechanisms, you can maintain your well-being and succeed in your nursing education.

Being Prepared Is Key!

Preparation is the key to reducing stress and anxiety before your clinical rotations. Here are some helpful strategies to help you feel confident and ready to tackle a rotation:

Academic Preparation

• Review Key Concepts: Review the key concepts and skills to reinforce your learning. Focus on areas where you feel less confident and seek additional resources or practice opportunities. (Osmosis quizzes are a great way to do this!)
• Understand Your Clinical Objectives: As a nursing student, know that every clinical exposure has its objectives and ideals. Understand the expectations and what you’re required to accomplish. Go through course syllabi, clinical guidelines, and other support materials.
• Brush-Up on Procedures: Familiarize yourself with standard nursing procedures and techniques using video instructions, practice on mannequins, or review using procedure checklists.
• Study Ahead: Use resources like Osmosis to review disease processes, procedures, and essential nursing skills. Understanding what to expect can help ease any anxiety you’re experiencing.

By focusing on mental and emotional preparation, academic review, and practical organization, you’ll set yourself up for a successful clinical experience. Remember, preparation is key, and a little effort upfront can make an enormous difference in your confidence and performance in the clinical setting. You’ve got this!

Developing Essential Skills

It’s all about communication in clinical settings; you need to practice communicating clearly and effectively with patients, families, and your healthcare team. Take the time to show empathy and actively listen. In addition to clinical skills, basic nursing procedures, and time management, practice critical thinking and use your problem-solving skills to help you make informed decisions under pressure.

Communication Skills

• Clear and Concise Communication: When communicating with patients, families, and colleagues, clarity is key. Use simple, straightforward language, and avoid medical jargon. Ensure your messages are concise and to the point to help prevent misunderstandings.
• Empathy and Compassion: Actively practice using empathy and compassion in your interactions. Patients and their families are often going through challenging times, and a little kindness and understanding can go a long way. Listen to their concerns, validate their feelings, and offer support. Empathy helps build trust and rapport and is essential for effective patient care.
• Active Listening: Active listening is putting in the effort to fully focus on the speaker, understand their message, and respond thoughtfully. It’s more than just hearing words; it’s about understanding the underlying emotions and concerns. Practice listening closely, maintaining eye contact, and nodding as people speak while providing feedback. This helps whoever you’re talking to feel that you value their input and are genuinely interested in what they have to say.
• Nonverbal Communication: Nonverbal cues, like body language, facial expressions, and tone of voice, play an essential role in communication. Be mindful of any nonverbal signals you may be giving and ensure they align with your verbal messages. For example, maintaining an open posture by uncrossing your arms, facing who you’re speaking to, and making eye contact can convey attentiveness and empathy.
• Documentation: Accurate and timely documentation is a critical aspect of communication in nursing. Make sure to document patient information, the care provided, and any changes in condition thoroughly and promptly. Clear documentation helps maintain continuity of care while also providing a legal record of the care provided.

One-Minute Check-In: Quickly check your patient’s vital signs, consciousness level, pain, general appearance, and any immediate concerns to help you prioritize tasks and identify urgent issues.

• Give Report: If available at your facility, use a tool like SBAR (Situation, Background, Assessment Recommendation, see graphic above) or a similar format to ensure concise and effective communication with your clinical instructor and healthcare team.
• Stay Calm During Med Passes: Double check the five rights of medication administration (right patient, right drug, right dose, right route, right time). If you’re uncertain, ask for help. Taking your time can prevent errors and reduce anxiety.

Practicing Self-Care

Self-care is crucial for maintaining your well-being during clinical rotations. Here are some strategies to help you manage stress:

• Get Enough Sleep: Aim for 7-9 hours to stay alert and focused.
• Eat a Balanced Diet: Choose nutritious foods to maintain your energy levels throughout the day.
• Exercise Regularly: Incorporate physical activity into your routine to reduce stress and improve your mood.
• Practice Mindfulness: Techniques such as deep breathing, yoga, or meditation can help manage anxiety and improve focus.

Seek Support

Don’t hesitate to seek support from peers, faculty, and mental health professionals:

• Peer Support: Form groups with classmates to share knowledge and experiences. Having a support network can help you feel less isolated.
• Faculty and Mentors: Reach out to your instructors and mentors for guidance and support. They can offer valuable advice and reassurance.
• Counseling Services: Take advantage of your school’s counseling services if you feel overwhelmed. Talking to a professional can provide strategies for managing stress and anxiety.

Reflecting and Learning

Taking time to reflect on and learn from your experiences can help you grow as a nurse. Consider:

• Journaling Your Experiences: Keep a journal to reflect on your clinical experiences, what you’ve learned, and areas where you feel you need improvement.
• Asking for Feedback: Ask for feedback from your clinical instructor and peers to help you identify strengths and areas for growth.

Understanding Common Challenges

Clinical rotations come with unique challenges that can test your skills and resilience. Having established ways to manage stress and anxiety is key. Let’s explore some of the challenges and opportunities you may encounter during clinical rotations. Understanding them can help you navigate your journey with resilience and confidence.

• Balancing Act: Balancing clinical hours, coursework, and personal life can be overwhelming. Staying organized and setting priorities can help you manage your time effectively.
• Emotional Strain: Caring for patients, especially those with severe conditions, can be emotionally taxing. Finding healthy ways to process and cope with these experiences is crucial. And remember, you can’t pour from an empty cup (in other words, self-care isn’t selfish; take care of yourself)!
• High Expectations: The pressure to perform well and meet the expectations of instructors and healthcare teams can be daunting. Keep in mind that making mistakes is part of the learning process.

Embracing Opportunities

Despite the challenges, clinical rotations in nursing offer numerous opportunities for growth and development:

• Hands-On Experience: Clinical rotations provide the opportunity to apply classroom knowledge in real-world settings. This hands-on experience is invaluable for building confidence and competence.
• Skill Development: Each rotation allows you to develop and refine essential nursing skills, from patient assessments to medication administration.
• Professional Networking: Interacting with other healthcare professionals and peers can help you build a network of contacts that may benefit your future career.

Finding Work-Life Balance

Maintaining a healthy work-life balance is crucial for long-term success in nursing. Here are some tips to help you achieve balance:

• Stay Organized: Being organized can help you manage your time and reduce stress. Use a planner to keep track of shifts, assignments, and personal commitments.
• Establish Clear Boundaries: Learn to set boundaries to ensure you have time for rest and relaxation. It’s important to disconnect from work and school to recharge.
• Prioritize Self-Care: Make time for activities that enhance your well-being, such as exercise, hobbies, and spending time with loved ones. (And don’t feel guilty about it! Downtime is essential.)
• Seek Support: Don’t hesitate to reach out to friends, family, or counselors for support. Building a strong support network can help you navigate challenges and maintain balance.

Additional Resources

For more resources and support, check out the following links:

• Osmosis Nursing Videos: Enhance your understanding of various nursing topics.
• Nursing Central: An app with drug guides, disease information, and more.
• American Academy of Pediatrics: Access resources for pediatric nursing.
• American Psychiatric Nurses Association: Explore resources for psychiatric nursing.
• Association of Women’s Health, Obstetric and Neonatal Nurses: Offers resources for OB nursing.

Acknowledgments

Special thanks to the educators, mentors, and peers who support and guide nursing students through their educational journey. Your dedication and expertise make a meaningful impact on the future of nursing.

Contributors and Reviewers 

Maria Pfrommer, DNP, Ph.D., FNP-BC, RN, Director of Nursing Education 

Elizabeth Lucas, EdD, RN, CNE, Senior Content Manager

Kelsey LaFayette, DNP, ARNP, FNP-C, Senior Content Manager 

Lisa Miklush, PhD, RN, CNS, Senior Content Editor 

Paige Randall, MS, RN, CNE, CEN, Script Writer and Editor 

Appendix: Support Documentation

Nursing Student Clinical Report Sheet

Instructions

The following clinical reports help you organize and document necessary patient information during your clinical rotations. Follow the instructions below to ensure you gather comprehensive data and communicate effectively with your nursing instructor and the healthcare team. Remember to always maintain HIPAA compliance by only using patient initials and avoid using identifiable information.

Using the Report Sheet

Use this report sheet to document critical patient information and apply your critical thinking skills to your clinical practice. This structured approach will enhance your critical thinking skills and support effective patient care.

Instructions

The following clinical report sheet is designed to help you organize and document important patient information during your clinical rotations. Follow the instructions below to ensure you gather comprehensive data and communicate effectively with your nursing instructor and the healthcare team. Remember to always maintain HIPAA compliance by only using patient initials and avoiding any use of identifiable information.

Nursing Student Clinical Report Sheet

Student Information

Field	Details
Name:
Date:
Clinical Instructor:
Preceptor/Nurse on the Floor:

Patient Information

Field	Details
Patient Initials:
Room/Bed Number:
Age:
Gender:

Admission Details

Field	Details
Admission Date:
Reason for Admission:
Primary Medical Diagnosis:
Secondary Medical Diagnoses:

Vital Signs

Vital Sign	Measurement
Temperature:
Pulse:
Blood Pressure:
Respiratory Rate:
Oxygen Saturation:
Pain Level (0-10):

Data Collection

Aspect	Findings
General Appearance:
Skin Condition:
Breathing Effort:
Level of Consciousness:
Orientation (Person, Place, Time):
IV Fluids (Type and Rate):
Urinary Catheter (Yes/No, Output):
Wound Care (Location, Type, Drainage):
Other Findings:

Medications

Type	Details
Scheduled Medications:	Medication Name, Dosage, Route, Time
	Medication Name, Dosage, Route, Time
PRN Medications:	Medication Name, Dosage, Route, Time, Indication
	Medication Name, Dosage, Route, Time, Indication

Treatments and Procedures

Type	Details
Scheduled Treatments:	Treatment Description, Time
	Treatment Description, Time
Completed Procedures:	Procedure Description, Time
	Procedure Description, Time

Care Plan

Outline the nursing care plan, including nursing priorities, goals, interventions, and evaluation, based on the information you’ve gathered on this patient.

Aspect	Details
Nursing priorities
Goals:
Interventions:	Intervention Description, Time
	Intervention Description, Time
Evaluation:

Patient Education Plan

Aspect	Details
Topics Discussed:
Patient Understanding:

Notes/Comments

Aspect	Details
Observations:
Concerns:
Plan for Next Shift:

Sign-Off

Field	Details
Nursing Student Signature:
Nursing Instructor Signature:
Date:

Happy learning, and best of luck on your journey to becoming a nurse!

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