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:

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Ordered Activity Level:
Assistive devices needed:

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

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Respiratory Respiratory

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

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Role – Relationship Pattern

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 se te e Therapeutic & assessments, common side
(Trade) 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:

2007 winter 50899068.doc

 Plan of Care

(1point) Evaluation of Expected Outcome:

Total Points _________(8)

2007 winter 50899068.doc