Major Client Data Packet For Grading YES NONURS 112, Revised 4.8.10

Important: Absolutely no patient identifiers from the medical record may be used on this data packet (HIPAA).

Student Name _____________________________________________ Clinical Week (1,2,3)_________________________

Instructor Name __________________________________ Unit _______________________________________

Age_______ ♀ ♂ CODE STATUS_________HT_______Admit WT________Current WT ________

Allergies______________________________________________________________________________________________

Admit VS______________________________________Admit Diagnosis__________________________________________

Other Medical Diagnoses ________________________________________________________________________________

______________________________________________________________________________________________________

Current Surgery (Post-Op Day)___________________________________________________________________________

Activity Level_________________________________Diet__________________________________________I/O: yes no

IV (site; solution & rate)__________________________________________ Pain Management:________________________

Support Tubes (type)/ Special Orders________________________________________________________________________

Social Support System____________________________________________________________________________________

List 2 anticipated Nursing Diagnoses:________________________________________________________________________ANTICIPATED PRIORITY FOCUSED ASSESSMENT

(Include rationale for why this is a priority)

ANTICIPATED PRIORITY NURSING DIAGNOSIS

(Include rationale for why you chose this as the highest priority nursing diagnosis)

ANTICIPATED NURSING INTERVENTIONS

(3 Minimum: Only 1 can be r/t assessment or monitoring)

EXPECTED OUTCOME:

NURS 112, Spring/2010Major Client Data Packet

1

PATHOPHYSIOLOGY

Admission Medical Diagnosis:

Textbook Etiology:

Client Specific Etiology:

Pathogenesis

Textbook Clinical Manifestations/ Signs & Symptoms:

Client Specific Clinical Manifestations/ Signs & Symptoms:

Integrate pertinent client/patient medical history (with instructor guidance):

Source of Pathophysiology (textbook and page number):

NURS 112, Spring/2010Major Client Data Packet

2

Medications - Scheduled(Highlight any medications that were discontinued prior to giving.)

Generic & Trade Name

Dose Route Time Classification &

Action

Nursing Implications(What do you need to know or do to give this medication safely?)

Evaluation of Medication Effects

Client’s reason for taking med

Medical reason for taking med

Therapeutic class Pharmacologic class Action of med

Assessment & common side effects Pertinent Labs Implementation Client/Family Teaching

What would you assess to know the med is working?

What were the results of your assessment?

NURS 112, Spring/2010Major Client Data Packet

3

Medications - PRN(List only those given in the last 24 hours. Highlight any medications that were discontinued prior to giving.)

Generic & Trade Name

Dose Route Time Classification &

Action

Nursing Implications(What do you need to know or do to give this medication safely?)

Evaluation of Medication Effects

Client’s reason for taking med

Medical reason for taking med

Therapeutic class Pharmacologic class Action of med

Assessment & common side effects Pertinent Labs Implementation Client/Family Teaching

What would you assess to know the med is working?

What were the results of your assessment?

NURS 112, Spring/2010Major Client Data Packet

4

Lab Values

Lab Test NormalRange

LabValues w/

Dates

RationaleIdentify pertinent labs (even if normal)

If lab is abnormal, explain why it is abnormal.

Assessment Findings(Based on the lab result, what would

you expect to see in your assessment?)

CBCRed Blood Cell (RBC) 4-6

Hemoglobin (Hgb) 12-18

Hematocrit (Hct) 38-54%

Platelet Count 150-400

White Blood Cell (WBC) 4-11

Differential Neutrophils - Segs - Bands

50-70%0-8%

Lymphocytes 20-40%

Monocytes 4-8%

Eosinophils 0-4%

Basophils 0-2%

RBC IndicesMCV (Mean Corpuscular Volume)

82-98 fl

MCH (Mean Corpuscular Hemoglobin)

27-33 pg

MCHC (Mean Corpuscular Hemoglobin Concentration)

32-36%

RDW (Red Blood Cell Distribution)

11-14.5% variation

NURS 112, Spring/2010Major Client Data Packet

5

Lab Values (continued)

Lab Test NormalRange

LabValues w/

Dates

RationaleIdentify pertinent labs (even if normal)

If lab is abnormal, explain why it is abnormal.

Assessment Findings(Based on the lab result, what would

you expect to see in your assessment?)

ELECTROLYTESSodium 135-145

Chloride 95-105

Potassium 3.5-5

CO2 20-30

Calcium 9-11

Anion Gap(Na + K) – (Cl + Bicarb)

6-17

RENAL BUN 10-20

Creatinine 0.5-1.5

BUN/ Creatinine Ratio 12-20

GFR >60

NURS 112, Spring/2010Major Client Data Packet

6

Lab Values (continued)

Lab Test NormalRange

LabValues w/

Dates

RationaleIdentify pertinent labs (even if normal)

If lab is abnormal, explain why it is abnormal.

Assessment Findings(Based on the lab result, what would

you expect to see in your assessment?)

LIVERAlkaline Phosphatase (ALP) 30-120

Aspartate Aminotransferase (AST)

10-40

Alanine Aminotransferase (ALT)

4-36

Total Bilirubin 0.2-1.3

Amylase 0-130

Lipase 0-160

Total Protein 6-8

Albumin 3.5-5

CARDIACCK-MB

Troponin – I

BNP < 100 pg/ml

Total Cholesterol 140-200 mg/dl

LDL <130 mg/dl

HDL ♀ > 55 mg/dl♂ > 45mg/dl

Triglycerides 40-190 mg/dl

Lab Values (continued)NURS 112, Spring/2010Major Client Data Packet

7

Lab Test NormalRange

LabValues w/

Dates

RationaleIdentify pertinent labs (even if normal)

If lab is abnormal, explain why it is abnormal.

Assessment Findings(Based on the lab result, what would

you expect to see in your assessment?)

MISCELLANEOUSFasting Glucose 70-100

Hgb A1C < 7

PTT 30-45 seconds *

*Therapeutic is 1.5-2.5 times the control

PT 12-15 seconds*

*Therapeutic is 1.5-2 times the control

INR (International Normalized Ratio)

2-3* * Desired ranges are different depending on indication.

Stool Guiac Neg

OTHER LABS: For example: Culture, Gram Stain, & Sensitivity (Blood, Urine, Sputum; ABGs; etc.)

Labs are divided into specific sections, but keep in mind that labs can be abnormal due to other problems. For instance, an ALP can be elevated due to bone abnormalities not just liver problems.

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P., & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems. Mosby/Elsevier

Pagana, K.D. & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, MI: Mosby/Elsevier.

Lab Values (continued)NURS 112, Spring/2010Major Client Data Packet

8

Lab Test NormalRange

LabValues w/

Dates

RationaleIdentify pertinent labs (even if normal)

If lab is abnormal, explain why it is abnormal.

Assessment Findings(Based on the lab result, what would

you expect to see in your assessment?)

NURS 112, Spring/2010Major Client Data Packet

9

UrinalysisColor/Clarity Yellow/

ClearSpecific Gravity 1.003-1.030

pH 4 - 8

Protein Negative

Blood Negative

Bilirubin Negative

Glucose Negative

Ketones Negative

Nitrites Negative

Leukocyte Esterase Negative

Microscopic:

WBCs Few to none

RBCs Few to none

Bacteria Negative

Casts Negative

Crystals Negative

Yeast Negative

Epithelials Negative on a good sample

NURS 112, Spring/2010Major Client Data Packet

10

Diagnostic Tests(Examples: X-Ray, MRI, CT, ECG)

Date Diagnostic Test Results and Nursing Implications

NURS 112 Spring 2010Major Client Data Packet

11

Physical Assessment (Highlight abnormal data or defining characteristics for problems)

Day OneGeneral Survey

CHANGES FROM DAY #1Day Two General Survey

Vital Signs Time____________ Time______________

Pain: Rating DescriptionPain: Rating Description

Pulse Oximetry Oxygen

Vital Signs Time _________ Time _________

Pain: Rating DescriptionPain: Rating Description

Pulse Oximetry Oxygen

Neurological/ Psychological Neurological/Psychological

EEN/ Mouth EEN/ Mouth

Cardiovascular Cardiovascular

Respiratory Respiratory

Gastrointestinal/GU Gastrointestinal/GU

Musculoskeletal Musculoskeletal

Integumentary Integumentary

Lines/Tubes/Dressings Lines/Tubes/Dressings

NURS 112 Spring 2010Major Client Data Packet

12

Functional Health Patterns (Gordon’s)(Highlight abnormal data/defining characteristics for problems)

Health Perception-Health Maintenance Pattern Cognitive – Perceptual Pattern

Activity – Exercise Pattern Coping – Stress Tolerance

Nutrition– Metabolic Pattern

% of diet eaten: _____________

Fluid intake ______________ml

Self Perception – Self Concept Pattern

Elimination Pattern Role – Relationship Pattern

Sleep – Rest Pattern Value – Belief Pattern

NURS 112 Spring 2010Major Client Data Packet

13

Refer to page 233 of your Fundamentals of Nursing textbook by Potter & Perry.

Draft Documentation (For student use only – do not turn into instructor.)

Date/Hour Nursing Progress Note

NURS 112 Spring 2010Major Client Data Packet

14

Documentation

Date/Hour Nursing Progress Note

NURS 112 Spring 2010Major Client Data Packet

15

Nursing Plan of CarePoints Achieved __________________

Nursing Diagnosis/Expected Outcome

PRIORITY # ________ (1 point)

Nursing Interventions ( 1.5 points)3 required

Rationale ( 1.5 points)Provide one for each intervention

Nursing Diagnosis R/T (1 point) (two part diagnostic statement)

Defining Characteristics (1 point)(cues from all client data)

Expected Outcome (1 point)

Evaluation of Expected Outcome (1 points)

Suggested Modifications (1 point)

NURS 112 Spring 2010Major Client Data Packet

16

Nursing Plan of CarePoints Achieved __________________

Nursing Diagnosis/Expected Outcome

PRIORITY # ________ (1 point)

Nursing Interventions ( 1.5 points)3 required

Rationale ( 1.5 points)Provide one for each intervention

Nursing Diagnosis R/T (1 point) (two part diagnostic statement)

Defining Characteristics (1 point)(cues from all client data)

Expected Outcome (1 point)

Evaluation of Expected Outcome (1 point)

Suggested Modifications (1 point)

NURS 112 Spring 2010Major Client Data Packet

17