Name:
MOTT COMMUNITY COLLEGE
DIVISION OF HEALTH SCIENCES - NURSING PROGRAMS
CLIENT CARE CLINICAL FOCUS: NRSG 120 – NRSG 250
Client Initials
Age
Gender
Room #
Dates of Care
Admitting Diagnosis (es):
Past Medical History:
Allergies:
1.
Provide the definition and pathophysiology for the client’s current medical diagnosis (es) and/or surgical
procedure (s).
2.
Based upon readings, list the signs and symptoms for a client with this medical diagnosis (es) and/or postoperative observations for the surgical procedure (s). At the end of the time you care for this client,
highlight or star (*) the signs and symptoms you have observed in this client.
Reference (s) of the above:
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3.
Date
List the CBC, electrolytes, and one other laboratory test for your client.
Lab
Normal Range
Client Results
WBC
RBC
HGB
HCT
PLAT
Na
K
CO2
Cl
BUN
Cr
Glucose
PT
PTT
INR
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Reason for Test
Nursing Interventions for abnormal results
(Include notification of health team members.)
4.
List any diagnostic tests ordered for your client (i.e. X-ray, MRI, or CT).
Date
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Test
Client Results
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Reason for Test
Preparation Pre- & Post-
5.
Formulate 2 priority nursing diagnoses with etiology for your assigned patient.
6.
Develop 2 expected outcomes with measurable outcome criteria for your patient. At the end of the time
you care for this client, determine whether these outcomes were met/unmet.
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7.
Describe the anticipated nursing interventions and rationales to be used in the care of a client with this
medical diagnosis and/or surgical procedure (s). Remember to include teaching and discharge planning,
when appropriate. Include care of invasive lines and treatments such as wound care.
Intervention
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Rationale (Scientific Explanation)
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8.
Describe all prescribed medications and IV solutions, including those with additives.
Drug, Dose, Route,
and Frequency
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Usual and maximum
dose.
Include 24 hr range, if
available.
Drug Classification
and Action
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Nursing Implications
(What must you
check or do prior to
administering this
medication?)
and
Major Side Effects
Why is this client
receiving this drug?