ER patient assessment and clinical log for MSN

Kingdom of Saudi Arabia

Ministry of Education

University of Hail

College of Nursing

المملكة العربية السعودية

وزارة التعليم

جامـعـة حـائل

كلية التمريض

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

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Patient

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Family or significant other

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Caregiver

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EMS personnel

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Bystander

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Use of translator

Medical Diagnosis:

Last oral intake:

Mechanism of injury (if any)

Types of Injuries (if any)

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Blast Forces (Explosions)

Blunt Forces

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A. motor vehicle collisions,

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B. automobile versus pedestrian collisions

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C. motorcycle collisions,

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D. sports-related activities,

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E. falls

Penetrating Forces

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A. Stab wounds

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B. Gunshot wounds

Type of Energy caused Injury/Trauma

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Mechanical energy

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Thermal energy

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Electrical energy

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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

Time

Blood Pressure

Temperature

Central & Peripheral Pulse

SpO2

GCS

Pain Severity

Location

Value

MAP

Route

Rate

Rhythm

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

Severity*

* Pain Scale used for severity assessment:

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FACES pain rating scale for patients approximately 3 years of age and older

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Visual analog scale for school-age children and adolescents

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FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children

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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

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Respiratory disease

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Cardiovascular disease; risk factors

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Neurologic disease

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Endocrine disease

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Hepatic disease

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Infectious disease

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Hematologic disease

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Immunosuppression

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Autoimmune disease

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Psychological disorders psychiatric or mental health

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Others, Specify:

Allergies

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Medication—prescription, OTC

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Food/beverages

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Latex

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Iodine

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Environmental

Immunization status

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Pneumococci

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Influenza

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Tetanus

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Childhood illnesses

Psychological/social/environmental factors

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Smoking:

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Substance and/or alcohol use/abuse:

Safety

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Possible/actual assault, abuse, or intimate partner violence

situations

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Use of seat belts

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Texting while driving

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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:

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Family structure

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Significant others

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Social agencies

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Religious affiliation

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Caregivers

Responsibilities

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Self

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Family

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Business

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Community

Cultural beliefs and practices:

Spirituality:

Living accommodations

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House

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Apartment

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Accessibility (e.g., stairs)

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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

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.)

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

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)

References

Student Name

Student ID

Date

Hospital

Instructor Name

Student Clinical Objectives for Clinical Duty

Instructor will observe student clinical objectives at the beginning of clinical duty

My (student) objective for this clinical day is to (student will list his objectives based on his plan of what to learn in this clinical duty):

Evaluation of Objectives

Instructor will observe and discuss student evaluation of his/her objectives at the end of clinical duty

I (student) has achieved the following of my planned clinical objectives:

Not-achieved Objectives

Reason(s)