ER patient assessment and clinical log for MSN Assignment

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ER patient assessment and clinical log for MSN Assignment

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image1.png Kingdom of Saudi Arabia

Ministry of Education

University of Hail

College of Nursing

 المملكة العربية السعودية

وزارة التعليم

جامـعـة حـائل

كلية التمريض

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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):

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Healthcare Record Number (HRN):
Age:
Gender:
Presenting Chief complaint:
Triage category:
Infection status: ER patient assessment and clinical log for MSN Assignment
Accompanied by:
Source of data collection/gathering

FORMCHECKBOX Patient

FORMCHECKBOX Family or significant other

FORMCHECKBOX Caregiver

FORMCHECKBOX EMS personnel

FORMCHECKBOX Bystander

FORMCHECKBOX Use of translator
Medical Diagnosis:
Last oral intake:
Mechanism of injury (if any)
Types of Injuries (if any) FORMCHECKBOX Blast Forces (Explosions)

Blunt Forces

FORMCHECKBOX A. motor vehicle collisions,

FORMCHECKBOX B. automobile versus pedestrian collisions

FORMCHECKBOX C. motorcycle collisions,

FORMCHECKBOX D. sports-related activities,

FORMCHECKBOX E. falls

Penetrating Forces

FORMCHECKBOX A. Stab wounds

FORMCHECKBOX B. Gunshot wounds
Type of Energy caused Injury/Trauma FORMCHECKBOX Mechanical energy

FORMCHECKBOX Thermal energy

FORMCHECKBOX Electrical energy

FORMCHECKBOX Chemical energy
Effected Organ of the Injury/Trauma
Trauma Score (Refer to Revised Trauma Score Appendix)

ER patient assessment and clinical log for MSN Assignment
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

Full Set of Vital Signs

Time Blood Pressure Temperature Central & Peripheral Pulse SpO2 GCS Pain Severity
Location Value MAP Route Value Location Rate Rhythm Quality
ER patient assessment and clinical log for MSN Assignment
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
ER patient assessment and clinical log for MSN Assignment
Pain Assessment
Palliative Factors
Provocative Factors
Quality
Region
Radiation
Severity*
Timing: Onset
Timing: Duration
Timing: Frequency
* Pain Scale used for severity assessment:

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

FORMCHECKBOX Visual analog scale for school-age children and adolescents

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

FORMCHECKBOX 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 FORMCHECKBOX Respiratory disease

FORMCHECKBOX Cardiovascular disease; risk factors

FORMCHECKBOX Neurologic disease

FORMCHECKBOX Endocrine disease

FORMCHECKBOX Hepatic disease

 FORMCHECKBOX Infectious disease

FORMCHECKBOX Hematologic disease

FORMCHECKBOX Immunosuppression

FORMCHECKBOX Autoimmune disease

FORMCHECKBOX Psychological disorders psychiatric or mental health

FORMCHECKBOX Others, Specify:
Allergies FORMCHECKBOX Medication—prescription, OTC

FORMCHECKBOX Food/beverages

FORMCHECKBOX Latex

FORMCHECKBOX Iodine

FORMCHECKBOX Environmental
Immunization status FORMCHECKBOX Pneumococci

FORMCHECKBOX Influenza

FORMCHECKBOX Tetanus

FORMCHECKBOX Childhood illnesses
Psychological/social/environmental factors
FORMCHECKBOX Smoking: ER patient assessment and clinical log for MSN Assignment
FORMCHECKBOX Substance and/or alcohol use/abuse:
Safety FORMCHECKBOX Possible/actual assault, abuse, or intimate partner violence

situations

FORMCHECKBOX Use of seat belts

FORMCHECKBOX Texting while driving

FORMCHECKBOX 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: FORMCHECKBOX Family structure

FORMCHECKBOX Significant others

FORMCHECKBOX Social agencies

FORMCHECKBOX Religious affiliation

FORMCHECKBOX Caregivers
Responsibilities FORMCHECKBOX Self

FORMCHECKBOX Family

FORMCHECKBOX Business

FORMCHECKBOX Community
Cultural beliefs and practices:
Spirituality:
Living accommodations FORMCHECKBOX House

FORMCHECKBOX Apartment

FORMCHECKBOX Accessibility (e.g., stairs)

FORMCHECKBOX 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 Trade Name Frequency Route 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
ER patient assessment and clinical log for MSN Assignment
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.)

NURSING CARE PLAN

(Provide 3 Nursing Diagnosis and write one Nursing Diagnosis per Page)

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

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

ER patient assessment and clinical log for MSN Assignment
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

ER patient assessment and clinical log for MSN Assignment
References

ER patient assessment and clinical log for MSN Assignment