fac.ksu.edu.safac.ksu.edu.sa/.../files/nur_317_new_clinical_package_0.docx · Web viewKing Saud University C ollege of Nursing 1st Semester SY 1438 – 1439 NURS 317 CLINICAL PACKAGE

King Saud UniversityCollege of Nursing

1st Semester SY 1438 – 1439

NURS 317 CLINICAL PACKAGE

Weekly assignment

NUR 317 Medical-Surgical Dept.

Marks

Student Marks

1. Patient profile 12. Laboratory and Diagnostic

Tests 1

3. Physical assessment sheet , Vital Signs, I& O

2

4. Literature Review 1.55. Medication sheet 1.56. Nursing care plan 3

TOTAL 10

Student Name________________________ :Student No________________ .

Week No __________________ Date______________________

Day_______________________ Instructor__________________




I - Patient Profile

1. Patient bed No:___________________________ Age: ______ Sex: ___F / ___ M2. Medical Diagnosis:_________________________________________________________3. Chief Complaint: __________________________________________________________4. History of Present Illness:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Past Health history: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Family history______________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Psychosocial History ______________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Allergies/ Medications ____________________________________________________________________________________________________________________________________________________





I – Laboratory Test Normal Value

Result Significance ( Normal / Abnormal)

II – Diagnostic Test


II - Laboratory and Diagnostic studies




SYSTEM PATIENT FINDINGS1 – NEUROLOGICAL

Cognitive

Behavioral

GCS Score Eye : ____ + Verbal ____ + Motor_____ = ____

Others

II – CARDIOVASCULARPulse: ____ BP _______ Strength ______ Edema ____________________Capillary Refill _____ sec. Others ___________________________

III – RESPIRATORYRR _________ O2 Sat ______ O2 Flow____

FIO2 _______ Work of Breathing _______________________________

IV – GASTROINTESTINALAbdominal Girth _____cm Firm ___ Soft ____ Tender____

Bowel Sounds _____________________________________________Bowel Movement __________________________________________Nutritional Status __________________________________________

Others : __________________________________________________

V – GENITOURINARYUrination Continent ______ Incontinent_______

Catheter________________________________ Urine Output___________

VI – MUSCULOSKELETALAmbulation


III - PHYSICAL ASSESSMENT



NURS 317 CLINICAL PACKAGE_______________________________________________Range of Motion ___________________________________________ Abnormalities LocationSpasticity _________________________________________________Flaccidity _________________________________________________Weakness _________________________________________________Paralysis _________________________________________________Deformity _________________________________________________

Others : VII – INTEGUMENTARY

Wound ___________________________________________________Skin Integrity ______________________________________________

Pressure ulcer _____________________________________________Hair and Nails _____________________________________________

VIII – PSYCHOSOCIAL Cultural Consideration

Emotional Well Being

Spiritual Considerations

Support Systems

IX – GENERALPain Scale Temperature

HygieneIntake ORAL ( ml)IVF ( ml) HOURLY

8:00 – 9:00 9:00 – 10:0010:00 – 11:0011:00 – 12:00

12:00 – 1:00TOTAL INTAKE





_

Output

IV - VITAL SIGNS SHEET


Emesis ( ml)Urine ( ml) HOURLY8:00 – 9:00

9:00 – 10:0010:00 – 11:0011:00 – 12:00

12:00 – 1:00TOTAL INTAKE




Literature Review

Medical Diagnosis _____________________________________________________Definition;_______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pathophysiology of disease:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signs & symptoms:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Causes:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Treatment:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





Nursing Care Plan 1

Patent Name &ID: …………………………………….. Room/bed NO:…………… Diagnosis: ……………………..……

Assessment (0.75 marks)

Nursing diagnosis (problem)

(0.25 marks)

Goals(0.25 marks)

Interventions(1.5 marks)

Evaluation(0.25 marks)

Subjective data;

Objective data;





Nursing Care Plan 2

Patent Name &ID: …………………………………….. Room/bed NO:…………… diagnosis: ……………………..……



(0.25 marks)

Goals(0.25 marks)



Subjective data;

Objective data;





Patent Name &ID: …………………………………….. Room/bed NO:…………… diagnosis: ……………………..……



(0.25 marks)

Goals(0.25 marks)




Nursing Care Plan 3



NURS 317 CLINICAL PACKAGESubjective data;

Objective data;

Medication sheet 1

Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……




NURS 317 CLINICAL PACKAGEName /Dose Route /

Frequency (0.5 marks )

Action(0.25 marks )

Indication(0.25

marks )

Side effects(0.25

marks )

Nursing role(0.5 marks )

Evaluation(0.25 marks )

Medication sheet 2


Name Dos Route Action Indication Side Nursing role Evaluation




NURS 317 CLINICAL PACKAGEe +time effects

Medication sheet 3





NURS 317 CLINICAL PACKAGEName Dos

eRoute +time

Action Indication Side effects

Nursing role Evaluation

Progress Notes


Documents

fac.ksu.edu.safac.ksu.edu.sa/.../files/nur_317_new_clinical_package_0.docx · Web viewKing Saud University C ollege of Nursing 1st Semester SY 1438 – 1439 NURS 317 CLINICAL PACKAGE