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Walla Walla Community College

NURS 111, Winter 2007

Client Data Packet

Student Name: Date of care: Client initials,


Age/ Room:

History of Present Illness (include information on length of disease course)

Date of Admission:

Admitting Medical/Surgical Additional Medical Diagnoses (list)


Diagnosis:

Name & definition of surgical procedure, if applicable

• Client data • Priority focused


(to be completed prior to clinical Assessment
experience) (to be completed prior to clinical
experience)

Ht: Wt:
(if available)

Code Status:

Allergies:

Ordered Activity Level:


Assistive devices needed:
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Diet: Swallowing
difficulty: yes/no (circle)

I&O: yes/no (circle)

IV (solution) Flow
Rate:

Pain Management:
PCA:

O2 _------------------------ L/min

Tubes: (Foley Catheter, NG tube,


surgical drains, etc)

Other:

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The following sections are to be completed prior to submission of folder

Pathophysiology and Signs & Symptoms of admitting diagnosis

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Source & page number: ____________________

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Laboratory/Diagnostic tests

Date/Abnormal Test Normal Client Specific Rationale for


Result Range abnormal values

Others:

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Source & page number: ____________________

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

Date: Date:
_____________________________ _____________________________
(document changes in assessment,
General Survey: only)
General Survey:

Vital Signs: Vital Signs:


Time: Time:
Time: Time:
Pain: Rating Description Pain: Rating Description
Pulse Oximetry: Pulse Oximetry:

Psychological: Psychological:

Neuro-Muscular: Neuro-Muscular:

Skin: (include Back and Buttocks) Skin: (include Back and Buttocks)

EEN/ Mouth: EEN/ Mouth:

Cardiovascular Cardiovascular

Respiratory Respiratory

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Upper/Lower Extremities Upper/Lower Extremities

Gastrointestinal Gastrointestinal

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FUNCTIONAL HEALTH PATTERNS
(Highlight abnormal data or defining characteristics for problems)

Health Perception-Health Maintenance Pattern

Activity - Exercise Pattern

Nutrition – Metabolic Pattern


% of diet eaten: _________ Fluid intake ______ cc

Elimination Pattern

Sleep-Rest Pattern

Cognitive- Perceptual Pattern

Coping - Stress Tolerance

Self Perception - Self Concept Pattern

Role – Relationship Pattern


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Value - Belief Pattern

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Date/Ho Nursing Progress Notes
ur

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Instructor Feedback

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Medications

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Name Do Rou Tim Classification – Nursing Implications
Generic s t e Therapeutic & assessments, common side
(Trade) e e Pharmacologic effects, implementation
Therapeutic Effect What do you need to think
(specific to client) about to give this medication
safely?

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Highlight
name if
medication
discontinued
prior to
giving

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Plan of Care

Nursing Diagnosis/Expected Outcome Nursing Interventions Rationale


(1 point ) Nursing Diagnosis/Etiology: (R/T) (1.5 points) 3 required (1.5 points)

(2 points) Defining Characteristics related to


Diagnosis (from client data sheet or physical
assessment)

(1 point) Expected Outcome:

(1point) Evaluation of Expected Outcome:

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Plan of Care

Total Points _________(8)

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