‫ كلية التمريض‬/ ‫جامعة قناه السويس‬

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Suez Canal University/ Faculty of Nursing
(Medical Surgical Nursing/ Clinical Assessment sheet 2nd year 2020/2021)

Student: ______________________________ Date of Care: ___________

Patient's name: Department :

Sex: Bed No :
Age: Admission date:
Allergies: Surgery:
Previous surgeries:[type/year]
Admission weight: Today's weight:
Height:
BMI:
Reason for Admission [patient’s own words]: Unexpected events/complications during
hospitalization:

Medical Diagnosis:

Respiratory:
Type Spontaneous Artificial airway
Rhythm Regular Irregular
Rate Abnormal Resp. Pattern:
Kussmaul,s Chyne-Stokes Biot's Resp. Other………………
Respi. Rate/hour
Chest Excursion Symmetrical Asymmetrical Retractions
O2 Therapy O2 percent ……L/M Device………………
%

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Broncho/pulmonary Hygiene Post. Percussion/ Coughing Techniques
Drainage Vibration
Suctioning Nasal Tracheal………………………….
Tracheal………………..
Resp. Monitoring O2 ABG results
Saturation PaO2 PH PaCO2 HCO3
……………
…..
Incentive MDI inhaler MDI albuterol atrovent
Spirometer
inhaler
q ___ hrs.
Breath sounds Clear Wheezes Rhonchi Crackle Friction rubs
Cough Dr Productive None
y
Bronchial Secretion Amount/hr. Color
Chest tube Location:…………………… Other……………………………….
Cardiovascular system:

Pulse Rate/ Hour b/m b/m b/m b/m b/m b/m b/m

Rhythm Regular Irregular Other………………...

Pulse Amplitude +4 +3 Full +2 Normal +1 Weak 0 Absent

Bounding
Heart sounds Normal: Murmur Friction rub

BP measurements/ hour / / / / / / / / / /

MAP

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Central Circulation Neck Vein distension Flat Distended Average

Peripheral Circulation Capillary Refill: < 3 sec. > 3 sec.

Peripheral temp. Warm Cool
Cyanosis/ Tongue Libs Ear lobe Nail bed
Cardiac Pacemaker: Other:
E.C.G comments………………………………………………………………………………………….

Edema 1+ ( 2+ 3+ (6mm) 4+ (8mm) Comments:…………………………

2mm) (4mm)
Neurological system:
Level of consciousness
Oriented/Alert Verbal Stimulus Unresponsive
Disoriented Lethargic Obtunded
Paralyzed Sedated
Eye Pupils: Normal Constricted Dilated
Pupil Dilatation: Reaction:
Equal Non-equal Brisk R L
Size:
Sluggish R L
L:…………….mm
R:…………….mm None R L

Speech Clear Slurred Moaning Absent Intubated

Reflex Cough Gag Babinski Corneal Other

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Gastrointestinal Assessment

Elimination Continent Incontinent Enema Colostomy

Diet NPO NG tube G Tube Daily meal

Tube feeding Type Rate Risk for aspiration

Drainage Tube Ryle Colostomy Other…………………………………………..

GIT S& S Vomiting Nausea Constipation Diarrhea

Abdominal exam. Distended Flat Ascites Tender

Soft Firm Guarding Bruising

Genitourinary Assessment

Voiding method Condom Catheter Diaper Others………………

Urination Frequency Continent Incontinent Anuria Polyuria Oliguria

Urinary Catheter Size…… Date Type……………….

inserted……………..

Urine assessment Time PH S. Gravity Glucose Ketones RBC

Intake

Output

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Integumentary Assessment

Skin condition Intact Moisture Turn & position Other…..

skin barriers w/ skin care q. 2
hrs
Skin Turgor Good Poor Wound dressing/ drain……………………………..
Location & Type:
Body temp.

Psychological State

Behavior Restless Agitated Anxious withdrawn Anger

Depressed Talkative Crying Other…………………………….

Cooperativ Uncooperative Combative Other……………..

e

Level of Activity

Activity Level Independe Assist Dependent

nt
Ad lib BR only Chair Ambulate

Bed Rest Assistance of walker

Assistive Assistive devices: Mechanical lift cane

devices:
Pain Pain PRN analgesic Continuous IV Other………………..
Complains analgesia

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Pain Assessment 0= None
1-3= Mild pain
4-6= Moderate
7-10- Worst pain

Discharge Plan/Long Term Needs:

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Teaching Needs:
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Pathophysiology (Describe pathophysiology of all primary or related illnesses. Include cellular level & layman’s terms)
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Medications (scheduled & prn)
Name/Dose/Route Class & Action Major Side Effects Nursing Implications Patient Education

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Lab Values & Diagnostic Test Results

a. Important lab tests to monitor Why? (Consider diagnosis, pre-existing conditions, medications, complications, etc.)

b. Hematology Normal values Patient’s Values (include serial labs) Significance for this patient
Date Date Date
WBC
Plt
Hgb
Hct
RBC

c. Chemistry Normal values Patient’s Values (include serial labs) Significance for this patient
K+
Na+
Cl-
CO2
BUN
Cr
Glucose
Albumin
d. Coagulation Normal values Patient’s Values (include serial labs) Significance for this patient
PT
INR
PTT

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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e. Urine Normal values Patient’s Values (include serial labs) Significance for this patient
Color
Appearance
Spec. gravity
PH
Glucose
Ketones
Nitrates
RBCs
WBCs
Casts
Protein
f. Other Normal values Patient’s Values (include serial labs) Significance for this patient

g. Pertinent radiological studies:

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h. Other diagnostics (e.g. ECG, EGD, echo):

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Date/Time Nurses Notes

Note: Nurses Notes are for additional information not included in the assessment or worksheet, such as events or procedures done during the shift.
Do not just repeat assessment information or list routine care included in the worksheet or that would be charted on flow-sheets

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Suez Canal University/ Faculty of Nursing
(Medical Surgical Nursing Care Plan)
Client Initials: Student: Date:

Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation

DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation

DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation
DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation
DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation
DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation
DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation

DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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 ‫ كلية التمريض‬/ ‫جامعة قناه السويس‬
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Assessment Nursing Client Goals/Desired Nursing Interventions/Actions/Orders and Rationale *I Evaluation
DX/Clinical Outcomes/Objectives
Problem
Subjective Problem Long Term:

R/T Short Term:

Objective

AEB

*I = Implementation. Check those interventions/actions/orders that were implemented.

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