NUR 3130 - Data Collection Tool PDF

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Nova Southeastern University College of Nursing Data Collection Tool NUR 3130 Student’s Name: _________________________________________ Date: ___________________ Primary RN’s Initials: ______________________________________________________________ Initial Report from Primary RN: Day 1 Thursday

Day 2 friday

One packet per patient

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Organized Report Received from the Primary RN and/or Information Retrieved from Patient’s Medical Record: Primary RN: _______________________ Patient’s Initial: ______ Room #:_____ Admission Date: _________ Chief Complaint: What brought the patient into the hospital? ______naseau pain _________________________________ ________________________________________________________________________________________ Admitting Dx: ___pancreatic (actual diagnosis)____________________________________________________________________ Medical Hx: ___has diabetes (history)____________________________________________________________________________ Surgical Hx: _______________________________________________________________________________ Psychosocial Hx: Marital status: _______Smoker: ______ Alcohol use: _______ Illicit drug use: ___________ Religion: ________ Ethnicity: __________________Age: _______ Sex: _____ Height: _____ Weight: ______ Activity level: _______________ Abnormal labs/tests____________________________ Code Status: ______ Vital Signs _______________________________Pain________________ O2: _____ Accu-checks__________ Allergies (medication and food): _____________ Diet: __________ IV Lines/Fluids ___________ I&O ______ Patient Assessment (from primary RN): negative assessment means everything is good (no problems)

Neurologic: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Integumentary: Musculoskeletal: List of things to follow-up from report (include when you should follow-up):

Pathophysiology Primary Patient Disorder: Pathophysiology from Textbook:

Textbook or Reference Information Causes of Disorder:

Compare Textbook with this Patient’s Presentation They drink a liter of vodka

Alcoholism Risk Factors Associated with Disorder:

Signs and Symptoms: Subjective Data (symptoms):

Subjective Data (symptoms):

Objective Data (signs): Objective Data (signs):

Potential Complications:

Textbook or Reference Source:

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CONCEPT MAP Nursing Diagnosis

Nursing Diagnosis

Subjective Data:

Subjective Data:

Objective Data:

Objective Data:

Reason for Seeking Health Care (Admitting Diagnosis)

Nursing Diagnosis

Nursing Diagnosis

Subjective Data: Subjective Data:

Objective Data: Objective Data:

PLAN OF CARE PRIORITY #1 Nursing Diagnosis:

Intervention (s) The nurse will

Expected Outcome: The patient will

PRIORITY #2 Nursing Diagnosis:

Intervention (s) The nurse will

Expected Outcome: The patient will

PRIORITY #3 Nursing Diagnosis:

Intervention (s) The nurse will

Expected Outcome: The patient will

PRIORITY #4 Nursing Diagnosis:

Intervention (s) The nurse will

Expected Outcome: The patient will

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Narrative Nurse’s Note: Day 1 Student’s Name: ______________________________________ Date: ___________________ Patient’s Initial: Date and Nurse’s Note Time

Room #: Signature

Narrative Nurse’s Note: Day 2 Student’s Name: ______________________________________ Date: ___________________ Patient’s Initial: Date and Nurse’s Note Time

Room #: Signature

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Generic and Trade Name of each Medication

List the Dose, Route, Frequency

Therapeutic Describe the Classification of Purpose and Medication Indication for Each Medication

List the Dose, Route, Frequency

Patient PRN Medications Therapeutic Describe the Classification of Purpose and Medication Indication for Each Medication

List the Major Side Effects

Medication Adm assessed prior to medication? Nur monitoring effec be evaluated and effectiveness of m

List the Major Side Effects

Medication Adm assessed prior to medication? Nur monitoring effec be evaluated and effectiveness of m

Patient Daily Medications

Generic and Trade Name of each Medication

(Insert additional medications on separate page)

Name and Type of IV Fluids

Rate

Intravenous Administration Site and Reason for IV Fluid? Insertion Date

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Assessment of I

Tab: Diagnostics: Lab New Lab Diagnostic Diagnostic Date and Time

Department

Type

Result Name

Complete Blood Count w/o Differential

Complete Blood

Result

Flag

Reference Ranges

WBC (10 x 3/uL)

Normal/High/Lo w

4.0-9.0

RBC (mill/cumm)

Normal/High/Lo w

3.90-4.98

Hemoglobin (gm/dL)

Normal/High/Lo w

12.0-15.5

Hematocrit (%)

Normal/High/Lo w

35-45

MCL (fL)

Normal/High/Lo w

81-93

MCH (pg)

Normal/High/Lo w

28-35

MCHC (gm/dL)

Normal/High/Lo w

33-37

RDW (%)

Normal/High/Lo w

11.4-15.2

Platelet Count (1000/mm3)

Normal/High/Lo w

140-400

Mean Platelet Volume (MPV) (fL)

Normal/High/Lo w

6.0-11.1

WBC (10 x 3/uL)

Normal/High/Lo

4.0-9.0

Count w/Differential

Basic Metabolic Panel

w RBC (mill/cumm)

Normal/High/Lo w

3.90-4.98

Hemoglobin (gm/dL)

Normal/High/Lo w

12.0-15.5

Hematocrit (%)

Normal/High/Lo w

35-45

MCL (fL)

Normal/High/Lo w

81-93

MCH (pg)

Normal/High/Lo w

28-35

MCHC (gm/dL)

Normal/High/Lo w

33-37

RDW (%)

Normal/High/Lo w

11.4-15.2

Platelet Count (1000/mm3)

Normal/High/Lo w

140-400

Mean Platelet Volume (MPV) (fL)

Normal/High/Lo w

6.0-11.1

Neutrophils (%)

Normal/High/Lo w

40-70

Lymphocytes (%)

Normal/High/Lo w

10-20

Monocyte Count

Normal/High/Lo w

Monocyte Percentage (%)

Normal/High/Lo w

Open text field (Immature Forms)

Normal/High/Lo w

Sodium (mEq/L)

Normal/High/Lo w

135-145

Potassium (mEq/L)

Normal/High/Lo

3.5-5.1

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5

w

Complete Metabolic Panel

Chloride (mEq/L)

Normal/High/Lo w

98-107

CO2 (mEq/L)

Normal/High/Lo w

22-29

Glucose (mg/dL)

Normal/High/Lo w

70-99

Blood Urea Nitrogen (mg/dL)

Normal/High/Lo w

6-20

Creatinine (mg/dL)

Normal/High/Lo w

0.50-1.00

Calcium (mg/dL)

Normal/High/Lo w

8.4-10.5

Sodium (mEq/L)

Normal/High/Lo w

135-145

Potassium (mEq/L)

Normal/High/Lo w

3.5-5.1

Chloride (mEq/L)

Normal/High/Lo w

98-107

CO2 (mEq/L)

Normal/High/Lo w

22-29

Glucose (mg/dL)

Normal/High/Lo w

70-99

Blood Urea Nitrogen (mg/dL)

Normal/High/Lo w

6-20

Creatinine (mg/dL)

Normal/High/Lo w

0.50-1.00

Calcium (mg/dL)

Normal/High/Lo w

8.4-10.5

Total Protein (gm/dL)

Normal/High/Lo w

6.4-8.4

Albumin (gm/dL)

Normal/High/Lo w

3.5-5.2

Total Bilirubin (mg/dL)

Normal/High/Lo w

0.0-1.2

AST (U/L)

Normal/High/Lo w

0-32

Alkaline Phosphate (U/L)

Normal/High/Lo w

35-105

ALT (U/L)

Normal/High/Lo w

0-33

EGFR (ml/min/1.73m2)

Normal/High/Lo w

Total Cholesterol (mg/dL)

Normal/High/Lo w

Less than 200

Triglycerides (mg/dL)

Normal/High/Lo w

Less than 150

HDL Cholesterol (mg/dL)

Normal/High/Lo w

Greater than 40

LDL Cholesterol

Normal/High/Lo w

Less than 100

Prothrombin Time (sec)

Normal/High/Lo w

11.5-15.0

INR

Normal/High/Lo w

0.81-1.20

Partial Thromboplastin Time (PTT)

PTT (sec)

Normal/High/Lo w

23.5-37.5-1.20

Hepatic Panel

Albumin (grams/dl)

Normal/High/Lo w

3.5-5.0

Alkaline phosphatase, sodium (IU/Liters)

Normal/High/Lo w

30-120

ALT (SPGT) (IU/Liters)

Normal/High/Lo w

24-36

AST (SGOT) (IU/Liters)

Normal/High/Lo w

0-35

Lipid Panel

Prothrombin Time (PT)

14

HbA1c

Bilirubin, direct (mg/dL)

Normal/High/Lo w

0.1-0.3

Bilirubin, total (mg/dL)

Normal/High/Lo w

0.3-1.0

Protein, total, serum (g/dL)

Normal/High/Lo w

6.4-8.3

Glycohemoglobin (%)

Normal/High/Lo w

0.0-6.4

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Other

Normal/High/Lo w

Tab: Vital Signs Subtab: New Vital Sign Record Date and Time Blood Pressure:

/ Blood Pressure Position Check one Sitting Standing Supine Prone Left side lying Right side lying

Temperature

°F/C

Tab: Assessment 16

Subtab: Pain Scale Assessment Date and Time Pain Location Onset Pain Duration

Pain Frequency

Constant

Intermittent

Type of Pain Chronic

Acute Cancer-Related

Pain Goal Check one 0

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2

3

4

5

6

7

8

9

10

Pain Goal Notes:

Aggravating Factors Movement Coughing Aggravating Factors Comments:

Breathing

Alleviating Factors Rest Compression Alleviating Factors Comments:

Eating

Medication

Ice

Immobility

Pain Rating Check one 0

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2

Quality Of Pain Check all that apply Aching Burning Throbbing Piercing Dull Sore Stabbing Crushing

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4

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8

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Tab: Assessments

Subtab: Neuro Assessment Date and Time

Orientation Choose one

Person, Time, Place, Situation Disoriented

Check all that apply

Person Time Place Situation

Pupils Check one Both Eyes, Size 1 2 3 4 5 6 7 Reaction Check all that apply Brisk Accommodation Sluggish Fixed Blown

Strength Check where applicable Moves Well Upon Request Weak Movement Upon Request Moves Well When Stimulated Weak Movement When Stimulated No Movement

LUE

RUE

LLE

RLE

Tab: Assessments 18

Behavioral/Emotional Check one Calm Cooperative Restless Combative Confused Agitated Untestable

Subtab: Cardio Assessment Date and Time

Capillary Refill Check one per column All

LUE

RUE

LLE

< 3 sec > 3 sec Absent

Skin Color and Description Check all that apply Appropriate for ethnicity Warm Dry Intact Cool

Tab: Assessments Subtab: Respiratory

RLE

Pulses Check one per column All LUE Absent Intermittent +1 +2 +3 Bounding Doppler

Edema Check one per column All LUE Absent Trace 1+ 2+ 3+ 4+ NonPitting Pitting Anasarca

Clammy Cyanotic Diaphoretic Blotchy Dusky

Flushed Fragile Jaundiced Moist Mottled

Pale Ashen

RUE

RUE

LLE

LLE

RLE

RLE

Assessment Date and Time

Methods Chose one Room Air Nasal Cannula Simple Face Mask Mist tent Trach Collar T-Piece Ambu Bag NRB mask CPAP BiPAP Blow-by Other (specify)

% L/min % % % % % % % % %

Airway Device Check all that apply ETT Nasopharyngeal Mask Laryngeal Mask

Sputum Check all that apply Color Copious Bloody Serous White Creamy Green Clear Respiratory Symptoms Check all that apply Cough Shortness of Breath Difficulty Breathing at Rest Cyanosis Hypoventilating

Tracheostomy Nasal Trumpet Oral Airway

Amount Serosanguinous None Thin Tenacious Moderate

Yellow Purulent Black Brown Tan Blood Tinged

Hyperventilating Decreased Smell Deformity Epistaxis Use of Accessory Muscles

Breath Sounds 20

Nasal Drainage Difficulty Breathing with Activity Other:

Right Upper Lobe, Check all that apply Clear Rales Crackles Rhonchi Wheeze

Coarse Inspiratory Expiratory Decreased Diminished

Absent Stridor Anterior Posterior

Left Upper Lobe, Check all that apply Clear Rales Crackles Rhonchi Wheeze

Coarse Inspiratory Expiratory Decreased Diminished

Absent Stridor Anterior Posterior

Right Middle Lobe, Check all that apply Clear Rales Crackles Rhonchi Wheeze

Coarse Inspiratory Expiratory Decreased Diminished

Absent Stridor Anterior Posterior

Left Lower Lobe, Check all that apply Clear Rales Crackles Rhonchi Wheeze

Coarse Inspiratory Expiratory Decreased Diminished

Absent Stridor Anterior Posterior

Right Lower Lobe, Check all that apply Clear Rales Crackles Rhonchi Wheeze

Coarse Inspiratory Expiratory Decreased Diminished

Absent Stridor Anterior Posterior

Respirations: Select all that apply Regular Irregular

Tab: Assessments

Labored Gasping

Grunting Retracting Nasal Flaring

Subtab: GI Assessment Date and Time Diet Tolerance Check one Excellent Adequate Inadequate NPO Other N/A

Bowel Sounds Check one per column All LUQ Present Hypoactive Hyperactive Absent

RUQ

LLQ

RLQ

Emesis Description Check one Clear Frothy Bilious Green Bloody Blood Tinged Coffee Ground Food Content Projectile

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Gastric Tubes Location Check one Nasogastric, Left Nare Nasogastric, Right Nare Orogastric Gastric Nasoduodenal tube

Gastric Tubes Draining Check one Capped Gravity Low Intermittent Suction Last Bo

Continuous Suction

Tab: Assessment Subtab: GU Assessment Date and Time Urine Odor

Urine Character Check one Clear Cloudy Concentrated Dilute Sediment Bloody Clots Frothy Purulent Abdominal Girth Cm Urinary Elimination Measure at (check one) Check all that apply Iliac Crests Voiding w/o Difficulty Umbilicus Voiding with Difficulty Site Marked Indwelling Catheter Inability to Void Straight Catheter Self Catheter Condom Catheter Surapubic Catheter 3-way Indwelling Catheter Urostomy Nephrostomy Tube Dialysis Ileal Conduit Catheter Date/time inserted Catheter Size (Fr) Volume In Balloon (mL) Site Description:

N/A

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Tab: Assessment Subtab: Integumentary: Braden Scale Mobility Check one Completely Immobile Very Limited Slight Limited No Limitations Total Score Friction Check one Shear Problem Potential Problem No Apparent Problem

Tab: Assessment Subtab: Musculoskeletal Assessment Date and Time

Weight Bearing / Gait None Check all that apply Steady Independent Unsteady Dependent Asymmetrical Jerky Shuffling Spastic Developmentally appropriate Lordosis Scoliosis Kyphosis N/A

Muscle Tone / Strength: Check each column All LUE RUE LLE Motor Strength Grade: Check all that apply 5/5 4/5 3/5 2/5 1/5 0/5 Range of Motion: Check all that apply Full ROM Impaired ROM Characteristic: Check One per column Spasm Paralysis Atrophy

Devices Cast Leg braces Back brace Boot Sling Cane Crutches Walker Wheelchair Chairfast Bedfast Prothesis Other: N/A

Other/Notes:

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RLE

Tab: ADLs ADL Assessment Date and Time

ADL Assessment Check all that apply Bed mobility Transfer Walking Dressing Eating Toilet Use Personal hygiene Bathing

Diet Consumption Select one 25% 50% 75% 100%

Communication Check all that apply Short-term memory intact Long-term memory intact Has ability to understand Has ability to make self understood Diet Assessment Check all that apply Increased appetite Decreased appetite Aspiration risk Difficulty chewing Speech Assessment Check all that apply Rate Rhythm Content Loudness Notes: Mood and Behavior Check all that apply Verbal expression of distress Loss of interest Sleep pattern disturbance Apathetic Notes:

Dysphagia Weight gain Weight loss

Fluency Quantity Articulation Pattern

Anxious Sad appearance Appropriate or patient...