Student Name ______________________________
NURS248:Internship Student Log
Ward: ____________________ Date: ____________
Biographical Information (2pts)
Patient Initials ____________
Age:__________
DOA: ___________________
Reason for admission: __________________________________________________________________
Admitting Diagnosis ____________________________________________________________________
Concurrent Diagnoses: __________________________________________________________________
Significance to the admitting diagnosis ____________________________________________________
Pertinent Diagnostic Investigations (18pts)
Test/Type
Patient Results
Normal Ranges
Correlation/Significance
Xrays
Scans
Current Treatment Modalities (10pts)
Interventions
Vital Signs
Physician Orders
Interventions
Activity:
Diet
Physician Orders
1.
2.
Medications
3.
Fluids
4.
IV –site/size
5.
Glucose
Wound care
Oxygen
Wound site
physiotherapy
Catheters
Drains
Surgical
Procedure
EET01-2014
Medications: Include Only Current Medications (Given by Student or Not) (20pts)
(5 Points each for each drug )
Drug name and class: Include Prescribed Dosage, Route & Frequency
Reason prescribed for this client
Method of action in this client:
Evaluation of drug effect:
Related nursing care (give at least 3)
Drug name and class: Include Prescribed Dosage, Route & Frequency
Reason prescribed for this client
Method of action in this client:
Evaluation of drug effect:
Related nursing care (give at least 3)
Drug name and class: Include Prescribed Dosage, Route & Frequency
Reason prescribed for this client
Method of action in this client:
Evaluation of drug effect:
Related nursing care (give at least 3)
Drug name and class: Include Prescribed Dosage, Route & Frequency
Reason prescribed for this client
Method of action in this client:
Evaluation of drug effect:
Related nursing care (give at least 3)
EET01-2014
PATIENT EDUCATION
Need
Topic
PHYSICAL ASSESSMENT DOCUMENTATION (20pts)
OBSERVATION
ASSESSMENT
COMMENTS
Cognitive
Conscious orientated X3 pupils equal/RTL
YES
NO
Psychomotor
Comfortable/Pain free
YES
NO
Affective
Smooth, warm & Intact with good turgor
YES
NO
Respirations even; no effort
YES
NO
Heart rate/rhythm regular
Equal size; without mass or lesions
YES
YES
NO
NO
VISITORS/FAMILY SUPPORT
VISITORS DURING SHIFT YES
NO
TIME:_________
Relationship to the patient:
Round, flat, non-tender
YES
NO
1.
Moves all limbs with full power
YES
NO
2.
Infusing as ordered by physician
YES
NO
3.
Wound site clean & dry
YES
NO
4.
Priority Need Nursing Care Plan (30pts)
Assessment (2pts)
Priority Need (Maslow) :
Needs Identified:
Nursing Diagnosis ( 3pts)
Planning - Formulate Goal (2.5pts)
Objective data:
Subjective data:
Nursing Interventions (1pt each)
Rationales (1pt each)
1.
2.
3.
4.
5.
Implementation (2pts each)
1.
2.
3.
4.
5.
Evaluation (2.5)
Total score: ____/100 = ____%
EET01-2014