ER patient assessment and clinical log for MSN

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1.ERPatientAssessmentNu1401.doc

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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

Student ID

Date

Hospital

Instructor Name

Patients Data

Patient’s name (First & surname):

Healthcare Record Number (HRN):

Age:

Gender:

Presenting Chief complaint:

Triage category:

Infection status:

Accompanied by:

Source of data collection/gathering

FORMCHECKBOX Patient

FORMCHECKBOX Family or significant other

FORMCHECKBOX Caregiver

FORMCHECKBOX EMS personnel

FORMCHECKBOX Bystander

FORMCHECKBOX Use of translator

Medical Diagnosis:

Last oral intake:

Mechanism of injury (if any)

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

Trauma Score (Refer to Revised Trauma Score Appendix)

Summary of the Primary Assessment:

List all abnormalities based on primary assessment (refer to Primary Assessment Guidelines)

History of Present Illness/injury/chief complaint

(Repeat this table for each of the symptoms)

Palliative Factors

Provocative Factors

Quality

Region

Radiation

Severity

Timing: Onset

Timing: Duration

Timing: Frequency

Treatment prior to arrival

Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis

Full Set of Vital Signs

Time

Blood Pressure

Temperature

Central & Peripheral Pulse

SpO2

GCS

Pain Severity

Location

Value

MAP

Route

Value

Location

Rate

Rhythm

Quality

Diagnostic Examinations/Procedures:

(Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)

Test/Procedure

Reference Value

(Normal Results)

Patient Results

Nursing Considerations

Pain Assessment

Palliative Factors

Provocative Factors

Quality

Region

Radiation

Severity*

Timing: Onset

Timing: Duration

Timing: Frequency

* 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

Patient’s definition of own health

past medical history (PMH), to include hospitalization/ surgeries:

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:

Allergies

FORMCHECKBOX Medication—prescription, OTC

FORMCHECKBOX Food/beverages

FORMCHECKBOX Latex

FORMCHECKBOX Iodine

FORMCHECKBOX Environmental

Immunization status

FORMCHECKBOX Pneumococci

FORMCHECKBOX Influenza

FORMCHECKBOX Tetanus

FORMCHECKBOX Childhood illnesses

Psychological/social/environmental factors

FORMCHECKBOX Smoking:

FORMCHECKBOX Substance and/or alcohol use/abuse:

Safety

FORMCHECKBOX Possible/actual assault, abuse, or intimate partner violence

situations

FORMCHECKBOX Use of seat belts

FORMCHECKBOX Texting while driving

FORMCHECKBOX Drinking and driving

Psychiatric history (personal or family members):

Literacy (level of Education)

Behavior appropriate for age and developmental stage:

Occupation/profession:

Meaning of illness, injury, or event to patient/family:

Patient’s/family’s expectations of care:

Support system:

FORMCHECKBOX Family structure

FORMCHECKBOX Significant others

FORMCHECKBOX Social agencies

FORMCHECKBOX Religious affiliation

FORMCHECKBOX Caregivers

Responsibilities

FORMCHECKBOX Self

FORMCHECKBOX Family

FORMCHECKBOX Business

FORMCHECKBOX Community

Cultural beliefs and practices:

Spirituality:

Living accommodations

FORMCHECKBOX House

FORMCHECKBOX Apartment

FORMCHECKBOX Accessibility (e.g., stairs)

FORMCHECKBOX Homeless, shelters

Affordability and accessibility to care—socioeconomic status:

History of descriptive and non-descriptive medications:

Descriptive medications (Prescribed by physician/doctor):

Generic Name & /

Classification

Trade Name

Dosage

Frequency

Route

Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):

Generic Name & /Classification

Trade Name

Frequency

Route

Rationale

Head-to-Toe Assessment (Review of Systems)

Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation)

General appearance

Skin/mucous membranes/nail beds

Head and face

Eyes/ Ear/ Nose/ Mouth/ Neck

Chest

Abdomen/flanks

Pelvis/perineum

Extremities

Posterior Surfaces

Currently Described Medications

Generic Name

(Dosage, Route, Frequency)

Trade Name/

Classification

Adverse Reactions

Nursing Responsibilities

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.)

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

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.

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

Assessment

Priority Nursing Diagnosis

Planning

Nursing intervention

Rationale

Evaluation

Subjective Data: What the client says about this problem

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.

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

Assessment

Priority Nursing Diagnosis

Planning

Nursing intervention

Rationale

Evaluation

Subjective Data: What the client says about this problem

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.

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

References

9

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