Mini-Client Data Packet

NURS 111

Student Name ______Date of Care______

Instructor Name ______Unit ______Room # ______

Client Initials______Age______Gender______CODE STATUS______
Allergies______
HT______Admit WT______Current WT______Admit VS______
Admit Diagnosis______
Other Medical Diagnoses______
______
Current Surgery (w/ date)______
Activity Level______Diet______I/O: yes no
IV (site; solution & rate)______
Support Tubes (type)/ Special Orders______
Pain Management______
Social Support System______
ANTICIPATED PRIORITY FOCUSED ASSESSMENT
(INCLUDE RATIONALE) / PROJECTED PRIORITY NURSING DIAGNOSIS with
EXPECTED OUTCOME
(INCLUDE RATIONALE FOR NURSING DIAGNOSIS) / PROJECTED NURSING INTERVENTIONS
(3 Minimum: Only 1 can be r/t assessment or monitoring)
EXPECTED OUTCOME:

PATHOPHYSIOLOGY

(Include etiology, Pathogenesis, & Clinical Manifestations/Signs & Symptoms)

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):

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Mini Data Packet

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
·  Implementation
·  Client/Family Teaching / ·  What would you assess to know the med is working?
·  What were the results of your assessment?

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
·  Implementation
·  Client/Family Teaching / ·  What would you assess to know the med is working?
·  What were the results of your assessment?

Lab Values

Lab Test / Normal
Range / Pertinent or
Abnormal
Values w/ Dates / Rationale
(If lab is normal, explain why the lab pertinent? 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?)
CBC
Red 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 Indices
MCV (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

Lab Values Continued

Lab Test / Normal
Range / Pertinent or
Abnormal
Values w/ Dates / Rationale
(If lab is normal, explain why the lab pertinent? 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?)
ELECTROLYTES
Sodium / 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

Lab Values Continued

Lab Test / Normal
Range / Pertinent or
Abnormal
Values w/ Dates / Rationale
(If lab is normal, explain why the lab pertinent? 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?)
Urinalysis
Color/Clarity / Yellow/
Clear
Specific 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

Lab Values Continued

Lab Test / Normal
Range / Pertinent or
Abnormal
Values w/ Dates / Rationale
(If lab is normal, explain why the lab pertinent? 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?)
LIVER
Alkaline 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
MISCELLANEOUS
Fasting Glucose / 70-100
Hgb A1C / 7
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.

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NURS 111, Winter/2010

Mini Data Packet

Diagnostic Tests

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

Date / Diagnostic Test / Results and Nursing Implications

Physical Assessment

(Highlight abnormal data or defining characteristics for problems)

Date ______
General Survey
/ CHANGES FROM DAY #1
Date ______
General Survey
Vital Signs Time______Time______
Pain: Rating Description
Pain: Rating Description
Pulse Oximetry Oxygen / Vital Signs Time ______Time ______
Pain: Rating Description
Pain: 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

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

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

Draft Documentation

Date/Hour / Nursing Progress Note

Documentation

Date/Hour / Nursing Progress Note

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NURS 111, Winter/2010

Mini Data Packet