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نسخة Weekly Report Nur 423 2021
نسخة Weekly Report Nur 423 2021
College of Nursing
2ND
Semester SY 1441 – 1442
(2020– 2021)
NURS 423 CLINICAL PACKAGE
Weekly report
(To be submitted before the next class)
Student Name: ______________Area __________Room/bed No._________
Diagnosis: ____________________________ Date: __________________ Week#_________
Marks Student
marks
1. Physical assessment sheet 2
2. Laboratory and Diagnostic 1
Tests
3. Nursing care plan 4
4. Medication 3
TOTAL 10
/2=5
Physical assessment
RM # Area Critical \ ER ----- bed# Admission Unit: CCU(coronary care Wt: 85KG
-------- Sex: male M\F day: unit) Height: 170CM
Age: 58Y/O 02 BMI: 29 (overweight)
MARCH 2020 @
13:08 pm Triage level in ER dep.:
Eye Opening
4 Spontaneous eye opening.
3 Eye opening in response to speech -
that is, any speech or shout.
2 Eye opening in response to pain.
1 No eye opening.
Wound
uniformity thin Old scar in the ICD site
Dressing
Drain output…….
NUR 423 Medical-Surgical Dept.
King Saud University
College of Nursing
2ND
Semester SY 1441 – 1442
(2020– 2021)
NURS 423 CLINICAL PACKAGE
anemia
* bone marrow failure
* erythropoietin deficiency, which is the primary
cause of anemia in patients with chronic kidney
disease
* hemolysis, or RBC destruction caused by
transfusions and blood vessel injury
* internal or external bleeding
* leukemia
* malnutrition
* multiple myeloma, a cancer of the plasma cells
in bone marrow
* nutritional deficiencies, including deficiencies in
iron, copper, folate, and vitamins B-6 and B-12
* pregnancy
* thyroid disorders
MCV 80 to 96 fl/red 90
cell in adult
ESR 20mmlh 46
HDL
1.0mmol\l 1.21
LDL 5.18
2.6mmol\l
* Malnutrition
* Infection
* Inflammatory bowel disease
* Thyroid disease
Higher than normal levels of albumin may indicate
dehydration or severe diarrhea.
Alk phos 211
19-146 iu\l
from. High alkaline phosphatase levels in the liver
can indicate:
Cirrhosis
Hepatitis
A blockage in the bile duct
Mononucleosis, which can sometimes cause
swelling in the liver
There are several other types of blood tests that
check your liver function. These include bilirubin,
aspartate aminotransferase (AST), and alanine
aminotransferase (ALT) tests. If these results are
normal and your alkaline phosphatase levels are
high, it may mean the problem is not in your liver.
Instead, it can indicate a bone disorder, such as
Paget's Disease of Bone, a condition that causes
your bones to become abnormally large, weak, and
prone to fractures.
heart disease
congestive heart failure
a recent heart attack
gastrointestinal bleeding
dehydration
high protein levels
kidney disease
kidney failure
dehydration
obstruction in the urinary tract
stress
shock
Keep in mind that some medications, such as
NUR 423 Medical-Surgical Dept.
King Saud University
College of Nursing
2ND
Semester SY 1441 – 1442
(2020– 2021)
NURS 423 CLINICAL PACKAGE
liver failure
malnutrition
severe lack of protein in the diet
overhydration
Potassium 4.8mmol\l 4.5
Too much potassium in the blood, a condition
:known as hyperkalemia, may indicate
* Kidney disease
* Burns or other traumatic injuries
* Addison's disease, a hormonal disorder that can
cause a variety of symptoms including weakness,
dizziness, weight loss, and dehydration
* Type 1 diabetes
* The effect of medicines, such as diuretics or
antibiotics
* In a rare instances, a diet too high in potassium.
Potassium is found in many foods, such as
bananas, apricots, and avocados, and is part of a
healthy diet. But eating excessive amounts of
potassium-rich foods can lead to health problems.
Too little potassium in the blood, a condition
:known as hypokalemia, may indicate
NUR 423 Medical-Surgical Dept.
King Saud University
College of Nursing
2ND
Semester SY 1441 – 1442
(2020– 2021)
NURS 423 CLINICAL PACKAGE
Echocardiogram
No thrombus, sever LV dysfunction, EF15%
CT brain Normal
1-
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-Suction as needed.
Subjective data. - - - -
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Objective data. - -
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Subjective data. - - - -
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Objective data. - -
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Subjective data. - - - -
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Objective data. - -
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1-
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7-
Medication sheet 1
Medication sheet 2
SKIN: Erythema
multiforme,
pruritus, purpura,
Stevens–Johnson
syndrome, toxic
epidermal
necrolysis,
urticaria
Other:
Anaphylaxis,
angioedema, fluid
overload, gout,
hyperkalemia,
hyper- uricemia,
hyponatremia,
hypovolemia, viral
infection, weight
gain or loss
Medication sheet 3
Patent Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……
Name of Classification / Indication Side effects Nursing role Evaluation
Drug Action of the
Dose Drug
Route
Frequency
- -Chemical To treat erosive CNS: Anxiety, Ensure the
class: esophagitis asthenia, confusion, continuity of
Substituted associated with depression, gastric acid
benzimidazole gastroesophagea dizziness, fatigue, suppression