NURS 111 Major Client Data Packet



Major Client Data Packet

NURS 111

Student Name _____________________________________________ Date of Care__________________________________

Instructor Name __________________________________ Unit ________________________ Room # ________

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|Client Initials__________________Age_______________Gender_______________CODE STATUS____________________ |

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|Allergies______________________________________________________________________________________________ |

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|HT__________Admit WT__________Current WT_________Admit VS___________________________________________ |

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|Admit Diagnosis________________________________________________________________________________________ |

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|Other Medical Diagnoses_________________________________________________________________________________ |

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|______________________________________________________________________________________________________ |

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|Current Surgery (w/ date)_________________________________________________________________________________ |

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|Activity Level_________________________________Diet__________________________________________I/O: yes no |

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|IV (site; solution & rate)__________________________________________________________________________________ |

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|Support Tubes (type)/ Special Orders________________________________________________________________________ |

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|Pain Management_______________________________________________________________________________________ |

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|Social Support System____________________________________________________________________________________ |

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|ANTICIPATED PRIORITY FOCUSED ASSESSMENT |PROJECTED PRIORITY NURSING DIAGNOSIS with |PROJECTED NURSING INTERVENTIONS |

|(INCLUDE RATIONALE) |EXPECTED OUTCOME |(3 Minimum: Only 1 can be r/t assessment or |

| |(INCLUDE RATIONALE FOR NURSING DIAGNOSIS) |monitoring) |

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| |EXPECTED OUTCOME: | |

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PATHOPHYSIOLOGY

(Include etiology, Pathogenesis, & Clinical Manifestations/Signs & Symptoms)

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|Admission Medical Diagnosis: |

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|Textbook Etiology: |

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|Client Specific Etiology: |

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|Pathogenesis |

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|Textbook Clinical Manifestations/ Signs & Symptoms: |

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|Client Specific Clinical Manifestations/ Signs & Symptoms: |

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|Integrate pertinent client/patient medical history (with instructor guidance): |

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|Source of Pathophysiology (textbook and page number): |

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Medications - Scheduled

(Highlight any medications that were discontinued prior to giving.)

|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |

| | | | |& |(What do you need to know or do to give this medication safely?) | |

| | | | |Action | | |

| | | | |Client’s reason for taking med |Assessment & common side effects |What would you assess to know the med is |

| | | | |Medical reason for taking med |Implementation |working? |

| | | | |Therapeutic class |Client/Family Teaching |What were the results of your assessment? |

| | | | |Pharmacologic class | | |

| | | | |Action of med | | |

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Medications - PRN

(List only those given in the last 24 hours. Highlight any medications that were discontinued prior to giving.)

|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |

| | | | |& |(What do you need to know or do to give this medication safely?) | |

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| | | | |Client’s reason for taking med |Assessment & common side effects |What would you assess to know the med is |

| | | | |Medical reason for taking med |Implementation |working? |

| | | | |Therapeutic class |Client/Family Teaching |What were the results of your assessment? |

| | | | |Pharmacologic class | | |

| | | | |Action of med | | |

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Lab Values

|Lab Test |Normal |Pertinent or |Rationale |Assessment Findings |

| |Range |Abnormal |(If lab is normal, explain why the lab pertinent? If lab is abnormal, explain why |(Based on the lab result, what would you expect |

| | |Values w/ Dates |it is abnormal.) |to see in your assessment?) |

|CBC | | | | | |

|Hemoglobin (Hgb) |12-18 | | | | |

|Hematocrit (Hct) |38-54% | | | | |

|Platelet Count |150-400 | | | | |

|White Blood Cell (WBC) |4-11 | | | | |

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|Differential Neutrophils | | | | | |

|- Segs |50-70% | | | | |

|- Bands |0-8% | | | | |

|Lymphocytes |20-40% | | | | |

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|Monocytes |4-8% | | | | |

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|Eosinophils |0-4% | | | | |

|Basophils |0-2% | | | | |

|RBC Indices | | | | | |

|MCH (Mean Corpuscular Hemoglobin) |27-33 pg | | | | |

|MCHC (Mean Corpuscular Hemoglobin |32-36% | | | | |

|Concentration) | | | | | |

|RDW (Red Blood Cell Distribution) |11-14.5% | | | | |

| |variation | | | | |

Lab Values Continued

|Lab Test |Normal |Pertinent or |Rationale |Assessment Findings |

| |Range |Abnormal |(If lab is normal, explain why the lab pertinent? If lab is abnormal, explain why |(Based on the lab result, what would you expect |

| | |Values w/ Dates |it is abnormal.) |to see in your assessment?) |

|ELECTROLYTES | | | | | |

|Chloride |95-105 | | | | |

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|Potassium |3.5-5 | | | | |

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|CO2 |20-30 | | | | |

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|Calcium |9-11 | | | | |

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|Anion Gap |6-17 | | | | |

|(Na + K) – (Cl + Bicarb) | | | | | |

|RENAL | | | | | |

|Creatinine |0.5-1.5 | | | | |

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|BUN/ Creatinine Ratio |12-20 | | | | |

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|GFR |>60 | | | | |

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Lab Values Continued

|Lab Test |Normal |Pertinent or |Rationale |Assessment Findings |

| |Range |Abnormal |(If lab is normal, explain why the lab pertinent? If lab is abnormal, explain why it|(Based on the lab result, what would you expect |

| | |Values w/ Dates |is abnormal.) |to see in your assessment?) |

|Urinalysis | | | | | |

|Specific Gravity |1.003-1.030 | | | | |

|pH |4 - 8 | | | | |

|Protein |Negative | | | | |

|Blood |Negative | | | | |

|Bilirubin |Negative | | | | |

|Glucose |Negative | | | | |

|Ketones |Negative | | | | |

|Nitrites |Negative | | | | |

|Leukocyte Esterase |Negative | | | | |

|Microscopic: | | | | | |

|RBCs |Few to none | | | | |

|Bacteria |Negative | | | | |

|Casts |Negative | | | | |

|Crystals |Negative | | | | |

|Yeast |Negative | | | | |

|Epithelials |Negative on a good | | | | |

| |sample | | | | |

Lab Values Continued

|Lab Test |Normal |Pertinent or |Rationale |Assessment Findings |

| |Range |Abnormal |(If lab is normal, explain why the lab pertinent? If lab is abnormal, explain why |(Based on the lab result, what would you expect |

| | |Values w/ Dates |it is abnormal.) |to see in your assessment?) |

|LIVER | | | | | |

|Aspartate Aminotransferase (AST) |10-40 | | | | |

|Alanine Aminotransferase (ALT) |4-36 | | | | |

|Total Bilirubin |0.2-1.3 | | | | |

|Amylase |0-130 | | | | |

|Lipase |0-160 | | | | |

|Total Protein |6-8 | | | | |

|Albumin |3.5-5 | | | | |

|MISCELLANEOUS | | | | | |

|Hgb A1C |< 7 | | | | |

|Stool Guiac |Neg | | | | |

|OTHER LABS: For example: Culture, | | | | | |

|Gram Stain, & Sensitivity (Blood, | | | | | |

|Urine, Sputum; ABGs; etc.) | | | | | |

Labs are divided into specific sections, but keep in mind that labs can be abnormal due to other problems. For instance, an ALP can be elevated due to bone abnormalities not just liver problems.

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P., & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems. Mosby/Elsevier

Pagana, K.D. & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, MI: Mosby/Elsevier.

Diagnostic Tests

(Examples: X-Ray, MRI, CT, ECG)

|Date |Diagnostic Test |Results and Nursing Implications |

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Physical Assessment

(Highlight abnormal data or defining characteristics for problems)

| |CHANGES FROM DAY #1 |

|Date _____________________________ |Date _____________________________ |

|General Survey |General Survey |

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|Vital Signs Time____________ Time______________ |Vital Signs Time _________ Time _________ |

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|Pain: Rating Description |Pain: Rating Description |

|Pain: Rating Description |Pain: Rating Description |

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|Pulse Oximetry Oxygen |Pulse Oximetry Oxygen |

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|Neurological/ Psychological |Neurological/Psychological |

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| EEN/ Mouth | EEN/ Mouth |

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|Cardiovascular |Cardiovascular |

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|Respiratory |Respiratory |

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|Gastrointestinal/GU |Gastrointestinal/GU |

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|Musculoskeletal |Musculoskeletal |

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|Integumentary |Integumentary |

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|Lines/Tubes/Dressings |Lines/Tubes/Dressings |

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Functional Health Patterns (Gordon’s)

(Highlight abnormal data/defining characteristics for problems)

|Health Perception-Health Maintenance Pattern |Cognitive – Perceptual Pattern |

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|Activity – Exercise Pattern |Coping – Stress Tolerance |

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|Nutrition– Metabolic Pattern |Self Perception – Self Concept Pattern |

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|% of diet eaten: _____________ | |

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|Fluid intake ______________ml | |

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|Elimination Pattern |Role – Relationship Pattern |

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|Sleep – Rest Pattern |Value – Belief Pattern |

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Refer to page 233 of your Fundamentals of Nursing textbook by Potter & Perry.

Draft Documentation

|Date/Hour |Nursing Progress Note |

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Documentation

|Date/Hour |Nursing Progress Note |

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Nursing Plan of Care

Points Achieved __________________

|Nursing Diagnosis, Expected Outcome, & Evaluation |Nursing Interventions ( 1.5 points) |Rationale (1.5 points) |

| |Minimum of 3 and no more than 3 |Provide one for each intervention |

| |Only 1 r/t assessment or monitoring | |

|Nursing Diagnosis R/T (1 point) | | |

|(two part diagnostic statement) | | |

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|Defining Characteristics (1 point) | | |

|(cues from all client data) | | |

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|Expected Outcome (1 point) | | |

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|Evaluation of Expected Outcome (1 point) | | |

|Was the goal met? Provide supporting data. | | |

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|Suggested Modifications (1 point) | | |

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