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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 Assessment


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

Ht: Wt: (if available)

Code Status:

Allergies:

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 1 2/4/2011


The following sections are to be completed prior to submission of folder
Pathophysiology and Signs & Symptoms of admitting diagnosis

Source & page number: ____________________

2007 111Data packet Winter 2 2/4/2011


Laboratory/Diagnostic tests

Date/Abnormal Test Result Normal Range Client Specific Rationale for abnormal values

Others:

Source & page number: ____________________

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

Date: _____________________________ Date: _____________________________


(document changes in assessment, only)
General Survey: 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

Respiratory Respiratory

Upper/Lower Extremities Upper/Lower Extremities

Gastrointestinal Gastrointestinal

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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

Role – Relationship Pattern

Value - Belief Pattern

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Date/Hour Nursing Progress Notes

Instructor Feedback

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Medications
Name Dose Route Time Classification – Therapeutic & Nursing Implications
Generic Pharmacologic assessments, common side effects,
(Trade) Therapeutic Effect (specific to implementation
client) What do you need to think about to give this medication
safely?

Highlight name if
medication
discontinued prior to
giving

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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:

(1point) Evaluation of Expected Outcome:

Total Points _________(8)

2007 winter 50899095.doc