King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
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__________________
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGE
I - Patient Profile
1. Patient bed No:___________________________ Age: ______ Sex: ___F / ___ M2. Medical Diagnosis:_________________________________________________________3. Chief Complaint: __________________________________________________________4. History of Present Illness:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. Past Health history: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Family history______________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. Psychosocial History ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. Allergies/ Medications ____________________________________________________________________________________________________________________________________________________
NUR 317 Medical-Surgical Dept.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGE
I – Laboratory Test Normal Value
Result Significance ( Normal / Abnormal)
II – Diagnostic Test
NUR 317 Medical-Surgical Dept.
II - Laboratory and Diagnostic studies
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGE
SYSTEMPATIENT FINDINGS1 – NEUROLOGICAL
Cognitive
Behavioral
GCS ScoreEye : ____ + Verbal ____ + Motor_____ = ____
Others
II – CARDIOVASCULARPulse: ____ BP _______ Strength ______ Edema ____________________Capillary Refill _____ sec. Others ___________________________
III – RESPIRATORYRR _________ O2 Sat ______ O2 Flow____
FIO2 _______ Work of Breathing _______________________________
IV – GASTROINTESTINALAbdominal Girth _____cm Firm ___ Soft ____ Tender____
Bowel Sounds _____________________________________________Bowel Movement __________________________________________Nutritional Status __________________________________________
Others : __________________________________________________
V – GENITOURINARYUrination Continent ______ Incontinent_______
Catheter________________________________ Urine Output___________
VI – MUSCULOSKELETALAmbulation
NUR 317 Medical-Surgical Dept.
III - PHYSICAL ASSESSMENT
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGE_______________________________________________Range of Motion ___________________________________________ Abnormalities LocationSpasticity _________________________________________________Flaccidity _________________________________________________Weakness _________________________________________________Paralysis _________________________________________________Deformity _________________________________________________
Others : VII – INTEGUMENTARY
Wound ___________________________________________________Skin Integrity ______________________________________________
Pressure ulcer _____________________________________________Hair and Nails _____________________________________________
VIII – PSYCHOSOCIAL Cultural Consideration
Emotional Well Being
Spiritual Considerations
Support Systems
IX – GENERALPain Scale Temperature
HygieneIntake ORAL ( ml)IVF ( ml) HOURLY
8:00 – 9:00 9:00 – 10:0010:00 – 11:0011:00 – 12:00
12:00 – 1:00TOTAL INTAKE
NUR 317 Medical-Surgical Dept.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGE
_
Output
IV - VITAL SIGNS SHEET
Literature Review
NUR 317 Medical-Surgical Dept.
Emesis ( ml)Urine ( ml) HOURLY8:00 – 9:00
9:00 – 10:0010:00 – 11:0011:00 – 12:00
12:00 – 1:00TOTAL INTAKE
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGEMedical Diagnosis _____________________________________________________Definition;_______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pathophysiology of disease:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signs & symptoms:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Causes:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Treatment:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NUR 317 Medical-Surgical Dept.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
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.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
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.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
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
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGESubjective data;
Objective data;
Medication sheet 1
Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……
NUR 317 Medical-Surgical Dept.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
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.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGEe +time effects
Medication sheet 3
Patent Name &ID: …………………………………….. Room/bed NO: …………… diagnosis: …………………..……
NUR 317 Medical-Surgical Dept.
King Saud UniversityCollege of Nursing
1st Semester SY 1438 – 1439
NURS 317 CLINICAL PACKAGEName Dos
eRoute +time
Action Indication Side effects
Nursing role Evaluation
Progress Notes
NUR 317 Medical-Surgical Dept.