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![Page 1: fac.ksu.edu.safac.ksu.edu.sa/.../files/nur_317_new_clinical_package_2.docx · Web viewNursing diagnosis (problem) (0.25 marks) Goals (0.25 marks) Interventions (1.5 marks) Evaluation](https://reader031.vdocuments.net/reader031/viewer/2022021823/5b3ee6e37f8b9aff118b72fb/html5/thumbnails/1.jpg)
King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Weekly assignment
NUR 317 Medical-Surgical Dept.
Marks
Student Marks
1. Patient profile 12. Laboratory and Diagnostic
Tests 1
3. Physical assessment sheet , Vital Signs, I& O
2
4. Literature Review 1.55. Medication sheet 1.56. Nursing care plan 3
TOTAL 10
Student Name________________________ :Student No________________ .
Week No __________________ Date______________________
Day_______________________ Instructor__________________
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Patient Profile
1. Patient bed No:___________________________ Age: ______ Sex: F / M2. Medical Diagnosis:_________________________________________________________3. Chief complaint: __________________________________________________________4. History of present illness:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. Past medical history: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Surgical history:____________________________________________________________________________________________________________________________________________________
7. Family history________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. Allergies/ Medications
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I – Laboratory Test Normal Value
Result Significance ( Normal / Abnormal)
II – Diagnostic Test
NUR 317 Medical-Surgical Dept.
Laboratory and Diagnostic studies
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
SYSTEM PATIENT FINDINGS1 – NEUROLOGICAL
Cognitive
Behavioral
Mental
GCS Score Eye : ____ + Verbal ____ + Mental_____ = ____
Others
II – CARDIOVASCULAR Pulse: ____ BP _______ Strength ______ Edema ____________________Capillary Refill _____ sec. Others ___________________________
III – RESPIRATORY RR _________ O2 Sat ______ O2 Flow____ FIO2 _______ Work of Breathing _______________________________
IV – GASTROINTESTINAL Abdominal Girth _____cm Firm ___ Soft ____ Tender____ Bowel Sounds _____________________________________________
Bowel Movement__________________________________________ Nutritional Status__________________________________________
Others : __________________________________________________
NUR 317 Medical-Surgical Dept.
PHYSICAL ASSESSMENT
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
V – GENITOURINARY Urination Continent ______ Incontinent_______ Catheter________________________________
Urine Output___________
VI – MUSCULOSKELETAL Location Spasticity _________________________________________________Flaccidity _________________________________________________Weakness _________________________________________________Paralysis _________________________________________________Deformity _________________________________________________
Others_________________________________________________ Range of Motion ___________________________________________
Others Range of Motion_____________________________________
VII – INTEGUMENTARY Wound ___________________________________________________Skin Integrity ______________________________________________
Pressure ulcer _____________________________________________Hair and Nails _____________________________________________
VIII – PSYCHOSOCIAL Cultural Consideration
Emotional Well Being
Spiritual Considerations
Support Systems
IX – GENERAL Pain Scale Temperature
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGEHygiene
VITAL SIGNS SHEET
NUR 317 Medical-Surgical Dept.
![Page 7: fac.ksu.edu.safac.ksu.edu.sa/.../files/nur_317_new_clinical_package_2.docx · Web viewNursing diagnosis (problem) (0.25 marks) Goals (0.25 marks) Interventions (1.5 marks) Evaluation](https://reader031.vdocuments.net/reader031/viewer/2022021823/5b3ee6e37f8b9aff118b72fb/html5/thumbnails/7.jpg)
King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
NUR 317 Medical-Surgical Dept.
![Page 8: fac.ksu.edu.safac.ksu.edu.sa/.../files/nur_317_new_clinical_package_2.docx · Web viewNursing diagnosis (problem) (0.25 marks) Goals (0.25 marks) Interventions (1.5 marks) Evaluation](https://reader031.vdocuments.net/reader031/viewer/2022021823/5b3ee6e37f8b9aff118b72fb/html5/thumbnails/8.jpg)
King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Literature Review
Medical Diagnosis _____________________________________________________Definition;_______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pathophysiology of disease:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signs & symptoms:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Causes:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Treatment:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Nursing Care Plan 1
Patent Name &ID: …………………………………….. Room/bed NO:…………… Diagnosis: ……………………..……
Assessment (0.75 marks)
Nursing diagnosis (problem)
(0.25 marks)
Goals(0.25 marks)
Interventions(1.5 marks)
Evaluation(0.25 marks)
Subjective data;
Objective data;
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Nursing Care Plan 2
Patent Name &ID: …………………………………….. Room/bed NO:…………… diagnosis: ……………………..……
Assessment (0.75 marks)
Nursing diagnosis (problem)
(0.25 marks)
Goals(0.25 marks)
Interventions(1.5 marks)
Evaluation(0.25 marks)
Subjective data;
Objective data;
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGE
Patent Name &ID: …………………………………….. Room/bed NO:…………… diagnosis: ……………………..……
Assessment (0.75 marks)
Nursing diagnosis (problem)
(0.25 marks)
Goals(0.25 marks)
Interventions(1.5 marks)
Evaluation(0.25 marks)
NUR 317 Medical-Surgical Dept.
Nursing Care Plan 3
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGESubjective data;
Objective data;
Medication sheet 1
Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGEName /Dose Route /
Frequency (0.5 marks )
Action(0.25 marks )
Indication(0.25
marks )
Side effects(0.25
marks )
Nursing role(0.5 marks )
Evaluation(0.25 marks )
Medication sheet 2
Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……
Name Dos Route Action Indication Side Nursing role Evaluation
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGEe +time effects
Medication sheet 3
Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……
NUR 317 Medical-Surgical Dept.
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King Saud UniversityCollege of Nursing
2ND Semester SY 1437 – 1438( 2016 – 2017)
NURS 317 CLINICAL PACKAGEName Dos
eRoute +time
Action Indication Side effects
Nursing role Evaluation
Progress Notes
NUR 317 Medical-Surgical Dept.