ER patient assessment and clinical log for MSN
Amira93PAGE
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Kingdom of Saudi Arabia Ministry of Education University of Hail College of Nursing |
المملكة العربية السعودية وزارة التعليم جامـعـة حـائل كلية التمريض |
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Emergency Nursing Care I Practical (NURS 516) Patient Assessment & Nursing Care Plan (10%) |
Student Name |
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Student ID |
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Date |
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Hospital |
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Instructor Name |
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Patients Data |
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Patient’s name (First & surname): |
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Healthcare Record Number (HRN): |
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Age: |
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Gender: |
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Presenting Chief complaint: |
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Triage category: |
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Infection status: |
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Accompanied by: |
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Source of data collection/gathering
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FORMCHECKBOX Patient FORMCHECKBOX Family or significant other FORMCHECKBOX Caregiver FORMCHECKBOX EMS personnel FORMCHECKBOX Bystander FORMCHECKBOX Use of translator |
Medical Diagnosis: |
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Last oral intake: |
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Mechanism of injury (if any) |
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Types of Injuries (if any) |
FORMCHECKBOX Blast Forces (Explosions) Blunt Forces FORMCHECKBOX A. motor vehicle collisions, FORMCHECKBOX B. automobile versus pedestrian collisions FORMCHECKBOX C. motorcycle collisions, FORMCHECKBOX D. sports-related activities, FORMCHECKBOX E. falls Penetrating Forces FORMCHECKBOX A. Stab wounds FORMCHECKBOX B. Gunshot wounds |
Type of Energy caused Injury/Trauma |
FORMCHECKBOX Mechanical energy FORMCHECKBOX Thermal energy FORMCHECKBOX Electrical energy FORMCHECKBOX Chemical energy |
Effected Organ of the Injury/Trauma |
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Trauma Score (Refer to Revised Trauma Score Appendix) |
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Summary of the Primary Assessment: List all abnormalities based on primary assessment (refer to Primary Assessment Guidelines) |
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History of Present Illness/injury/chief complaint (Repeat this table for each of the symptoms) |
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Palliative Factors |
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Provocative Factors |
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Quality |
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Region |
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Radiation |
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Severity |
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Timing: Onset |
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Timing: Duration |
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Timing: Frequency |
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Treatment prior to arrival |
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Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis |
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Full Set of Vital Signs
Time |
Blood Pressure |
Temperature |
Central & Peripheral Pulse |
SpO2 |
GCS |
Pain Severity |
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Location |
Value |
MAP |
Route |
Value |
Location |
Rate |
Rhythm |
Quality |
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Diagnostic Examinations/Procedures: (Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…) |
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Test/Procedure |
Reference Value (Normal Results) |
Patient Results |
Nursing Considerations |
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Pain Assessment |
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Palliative Factors |
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Provocative Factors |
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Quality |
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Region |
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Radiation |
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Severity* |
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Timing: Onset |
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Timing: Duration |
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Timing: Frequency |
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* Pain Scale used for severity assessment: FORMCHECKBOX FACES pain rating scale for patients approximately 3 years of age and older FORMCHECKBOX Visual analog scale for school-age children and adolescents FORMCHECKBOX FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children FORMCHECKBOX Numeric rating scale for older school-age children and adolescents |
Past Medical History |
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Patient’s definition of own health |
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past medical history (PMH), to include hospitalization/ surgeries: |
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Current or preexisting diseases/illness/injuries/surgeries |
FORMCHECKBOX Respiratory disease FORMCHECKBOX Cardiovascular disease; risk factors FORMCHECKBOX Neurologic disease FORMCHECKBOX Endocrine disease FORMCHECKBOX Hepatic disease |
FORMCHECKBOX Infectious disease FORMCHECKBOX Hematologic disease FORMCHECKBOX Immunosuppression FORMCHECKBOX Autoimmune disease FORMCHECKBOX Psychological disorders psychiatric or mental health FORMCHECKBOX Others, Specify: |
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Allergies |
FORMCHECKBOX Medication—prescription, OTC FORMCHECKBOX Food/beverages FORMCHECKBOX Latex FORMCHECKBOX Iodine FORMCHECKBOX Environmental |
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Immunization status
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FORMCHECKBOX Pneumococci FORMCHECKBOX Influenza FORMCHECKBOX Tetanus FORMCHECKBOX Childhood illnesses |
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Psychological/social/environmental factors |
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FORMCHECKBOX Smoking: |
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FORMCHECKBOX Substance and/or alcohol use/abuse: |
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Safety |
FORMCHECKBOX Possible/actual assault, abuse, or intimate partner violence situations FORMCHECKBOX Use of seat belts FORMCHECKBOX Texting while driving FORMCHECKBOX Drinking and driving |
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Psychiatric history (personal or family members): |
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Literacy (level of Education) |
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Behavior appropriate for age and developmental stage: |
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Occupation/profession: |
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Meaning of illness, injury, or event to patient/family: |
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Patient’s/family’s expectations of care: |
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Support system: |
FORMCHECKBOX Family structure FORMCHECKBOX Significant others FORMCHECKBOX Social agencies FORMCHECKBOX Religious affiliation FORMCHECKBOX Caregivers |
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Responsibilities
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FORMCHECKBOX Self FORMCHECKBOX Family FORMCHECKBOX Business FORMCHECKBOX Community |
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Cultural beliefs and practices: |
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Spirituality: |
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Living accommodations |
FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Accessibility (e.g., stairs) FORMCHECKBOX Homeless, shelters |
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Affordability and accessibility to care—socioeconomic status: |
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History of descriptive and non-descriptive medications: |
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Descriptive medications (Prescribed by physician/doctor): |
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Generic Name & / Classification |
Trade Name |
Dosage |
Frequency |
Route |
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Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC): |
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Generic Name & /Classification |
Trade Name |
Frequency |
Route |
Rationale |
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Head-to-Toe Assessment (Review of Systems) Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation) |
General appearance |
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Skin/mucous membranes/nail beds |
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Head and face |
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Eyes/ Ear/ Nose/ Mouth/ Neck |
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Chest |
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Abdomen/flanks |
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Pelvis/perineum |
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Extremities |
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Posterior Surfaces |
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Currently Described Medications |
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Generic Name (Dosage, Route, Frequency) |
Trade Name/ Classification |
Adverse Reactions |
Nursing Responsibilities |
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Treatments/Therapeutic Regimens/Doctor Orders rather than Medications (e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.) |
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NURSING CARE PLAN
(Provide 3 Nursing Diagnosis and write one Nursing Diagnosis per Page)
Assessment |
Priority Nursing Diagnosis |
Planning |
Nursing intervention |
Rationale |
Evaluation |
Subjective Data: What the client says about this problem
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Statement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data) |
Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame) Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month) |
Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist) |
Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goal Must have statement for each action Give specific text references for each intervention (name of text and page number). Be sure to attach a bibliography.
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Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented. |
Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart
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Assessment |
Priority Nursing Diagnosis |
Planning |
Nursing intervention |
Rationale |
Evaluation |
Subjective Data: What the client says about this problem
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Statement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data) |
Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame) Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month) |
Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist) |
Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goal Must have statement for each action Give specific text references for each intervention (name of text and page number). Be sure to attach a bibliography.
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Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented. |
Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart
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Assessment |
Priority Nursing Diagnosis |
Planning |
Nursing intervention |
Rationale |
Evaluation |
Subjective Data: What the client says about this problem
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Statement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data) |
Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame) Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month) |
Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist) |
Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goal Must have statement for each action Give specific text references for each intervention (name of text and page number). Be sure to attach a bibliography.
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Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented. |
Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart
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References |
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