King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

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__________________

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

Patient Profile

1. Patient bed No:___________________________ Age: ______ Sex: F / M2. Medical Diagnosis:_________________________________________________________3. Chief complaint: __________________________________________________________4. History of present illness:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Past medical history: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Surgical history:____________________________________________________________________________________________________________________________________________________

7. Family history________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Allergies/ Medications

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I – Laboratory Test Normal Value

Result Significance ( Normal / Abnormal)

II – Diagnostic Test

NUR 317 Medical-Surgical Dept.

Laboratory and Diagnostic studies

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

SYSTEM PATIENT FINDINGS1 – NEUROLOGICAL

Cognitive

Behavioral

Mental

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

Others

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

III – RESPIRATORY RR _________ O2 Sat ______ O2 Flow____ FIO2 _______ Work of Breathing _______________________________

IV – GASTROINTESTINAL Abdominal Girth _____cm Firm ___ Soft ____ Tender____ Bowel Sounds _____________________________________________

Bowel Movement__________________________________________ Nutritional Status__________________________________________

Others : __________________________________________________

NUR 317 Medical-Surgical Dept.

PHYSICAL ASSESSMENT

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

V – GENITOURINARY Urination Continent ______ Incontinent_______ Catheter________________________________

Urine Output___________

VI – MUSCULOSKELETAL Location Spasticity _________________________________________________Flaccidity _________________________________________________Weakness _________________________________________________Paralysis _________________________________________________Deformity _________________________________________________

Others_________________________________________________ Range of Motion ___________________________________________

Others Range of Motion_____________________________________

VII – INTEGUMENTARY Wound ___________________________________________________Skin Integrity ______________________________________________

Pressure ulcer _____________________________________________Hair and Nails _____________________________________________

VIII – PSYCHOSOCIAL Cultural Consideration

Emotional Well Being

Spiritual Considerations

Support Systems

IX – GENERAL Pain Scale Temperature

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGEHygiene

VITAL SIGNS SHEET

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

Literature Review

Medical Diagnosis _____________________________________________________Definition;_______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pathophysiology of disease:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signs & symptoms:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Causes:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Treatment:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

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;

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

Nursing Care Plan 2

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;

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGE

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)

NUR 317 Medical-Surgical Dept.

Nursing Care Plan 3

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGESubjective data;

Objective data;

Medication sheet 1

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

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

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

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

Name Dos Route Action Indication Side Nursing role Evaluation

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGEe +time effects

Medication sheet 3

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

NUR 317 Medical-Surgical Dept.

King Saud UniversityCollege of Nursing

2ND Semester SY 1437 – 1438( 2016 – 2017)

NURS 317 CLINICAL PACKAGEName Dos

eRoute +time

Action Indication Side effects

Nursing role Evaluation

Progress Notes

NUR 317 Medical-Surgical Dept.