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    Walla Walla Community College NURS 111, Winter 2007

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    الغزال الذهبي
    This document contains a client data packet for a nursing student to complete prior to a clinical experience. It includes sections to record the client's history, diagnoses, surgical procedures, lab results, physical assessments, functional health patterns, medications, and a plan of care. The plan of care requires identifying a nursing diagnosis related to the client's condition, relevant interventions, and an expected outcome to evaluate. This packet is intended to help the student prepare to assess and care for their assigned client.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Walla Walla Community College NURS 111, Winter 2007

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    الغزال الذهبي
    59 views18 pages
    This document contains a client data packet for a nursing student to complete prior to a clinical experience. It includes sections to record the client's history, diagnoses, surgical procedures, lab results, physical assessments, functional health patterns, medications, and a plan of care. The plan of care requires identifying a nursing diagnosis related to the client's condition, relevant interventions, and an expected outcome to evaluate. This packet is intended to help the student prepare to assess and care for their assigned client.

    Original Title

    200NURS101A673162181404002852007MajorwinterdatapacketNURS111

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    This document contains a client data packet for a nursing student to complete prior to a clinical experience. It includes sections to record the client's history, diagnoses, surgical procedures, lab results, physical assessments, functional health patterns, medications, and a plan of care. The plan of care requires identifying a nursing diagnosis related to the client's condition, relevant interventions, and an expected outcome to evaluate. This packet is intended to help the student prepare to assess and care for their assigned client.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    59 views18 pages

    Walla Walla Community College NURS 111, Winter 2007

    Uploaded by

    الغزال الذهبي
    This document contains a client data packet for a nursing student to complete prior to a clinical experience. It includes sections to record the client's history, diagnoses, surgical procedures, lab results, physical assessments, functional health patterns, medications, and a plan of care. The plan of care requires identifying a nursing diagnosis related to the client's condition, relevant interventions, and an expected outcome to evaluate. This packet is intended to help the student prepare to assess and care for their assigned client.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 18

    Walla Walla Community College

    NURS 111, Winter 2007

    Client Data Packet

    Student Name: Date of care: Client initials,


    Age/ Room:

    History of Present Illness (include information on length of disease course)

    Date of Admission:

    Admitting Medical/Surgical Additional Medical Diagnoses (list)


    Diagnosis:

    Name & definition of surgical procedure, if applicable

     Client data  Priority focused


    (to be completed prior to clinical Assessment
    experience) (to be completed prior to clinical
    experience)

    Ht: Wt:
    (if available)

    Code Status:

    Allergies:

    2007 111Data packet Winter 1 12/8/2021


    Ordered Activity Level:
    Assistive devices needed:

    Diet: Swallowing
    difficulty: yes/no (circle)

    I&O: yes/no (circle)

    IV (solution) Flow
    Rate:

    Pain Management:
    PCA:

    O2 _------------------------ L/min

    Tubes: (Foley Catheter, NG tube,


    surgical drains, etc)

    Other:

    2007 111Data packet Winter 2 12/8/2021


    The following sections are to be completed prior to submission of folder

    Pathophysiology and Signs & Symptoms of admitting diagnosis

    2007 111Data packet Winter 3 12/8/2021


    Source & page number: ____________________

    2007 111Data packet Winter 4 12/8/2021


    Laboratory/Diagnostic tests

    Date/Abnormal Test Normal Client Specific Rationale for


    Result Range abnormal values

    Others:

    2007 111Data packet Winter 5 12/8/2021


    Source & page number: ____________________

    2007 111Data packet Winter 6 12/8/2021


    Physical Assessment
    (Highlight abnormal data or defining characteristics for problems)

    Date: Date:
    _____________________________ _____________________________
    (document changes in assessment,
    General Survey: only)
    General Survey:

    Vital Signs: Vital Signs:


    Time: Time:
    Time: Time:
    Pain: Rating Description Pain: Rating Description
    Pulse Oximetry: Pulse Oximetry:

    Psychological: Psychological:

    Neuro-Muscular: Neuro-Muscular:

    Skin: (include Back and Buttocks) Skin: (include Back and Buttocks)

    EEN/ Mouth: EEN/ Mouth:

    Cardiovascular Cardiovascular

    2007 111Data packet Winter 7 12/8/2021


    Respiratory Respiratory

    Upper/Lower Extremities Upper/Lower Extremities

    Gastrointestinal Gastrointestinal

    2007 111Data packet Winter 8 12/8/2021


    FUNCTIONAL HEALTH PATTERNS
    (Highlight abnormal data or defining characteristics for problems)

    Health Perception-Health Maintenance Pattern

    Activity - Exercise Pattern

    Nutrition – Metabolic Pattern


    % of diet eaten: _________ Fluid intake ______ cc

    Elimination Pattern

    Sleep-Rest Pattern

    Cognitive- Perceptual Pattern

    Coping - Stress Tolerance

    Self Perception - Self Concept Pattern

    2007 111Data packet Winter 9 12/8/2021


    Role – Relationship Pattern

    Value - Belief Pattern

    2007 111Data packet Winter 10 12/8/2021


    Date/Ho Nursing Progress Notes
    ur

    2007 111Data packet Winter 11 12/8/2021


    Instructor Feedback

    2007 111Data packet Winter 12 12/8/2021


    Medications

    2007 111Data packet Winter 13 12/8/2021


    Name Do Rou Tim Classification – Nursing Implications
    Generic se te e Therapeutic & assessments, common side
    (Trade) Pharmacologic effects, implementation
    Therapeutic Effect What do you need to think
    (specific to client) about to give this medication
    safely?

    2007 111Data packet Winter 14 12/8/2021


    Highlight
    name if
    medication
    discontinued
    prior to
    giving
    2007 111Data packet Winter 15 12/8/2021
    2007 111Data packet Winter 16 12/8/2021
    Plan of Care

    Nursing Diagnosis/Expected Outcome Nursing Interventions Rationale


    (1 point ) Nursing Diagnosis/Etiology: (R/T) (1.5 points) 3 required (1.5 points)

    (2 points) Defining Characteristics related to


    Diagnosis (from client data sheet or physical
    assessment)

    (1 point) Expected Outcome:

    2007 winter 50899068.doc


    Plan of Care

    (1point) Evaluation of Expected Outcome:

    Total Points _________(8)

    2007 winter 50899068.doc

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