Robeson Community College
Department of Nursing
NUR 211/212
Adult Medical Surgical Clinical Packet
Section 1: Pre-Clinical Assessment
o Client Data Collection Form – To be completed during preclinical
o Pathophysiology
o Medical Analysis Cards
o Day of Care Map/Plan for clinical day
Section 2: Post Clinical
o Post clinical reflection – DEAL Method
o Submitted via email by 2355 on the day of the experience
Section 3: Concept Map (for a grade)
o Grading Rubric
o Preclinical Paperwork
o EBP Synopsis
o Nursing Process/Care Plan
o Evaluation of Care Provided and QSEN Competencies Met
1
,Section 1: Preclinical Assessment
Client Data Collection Form
Department of Nursing
Student Name:Hayley Farah Clinical SiteUNCS 6 Date: 10/2/24
Directions: The student is expected to complete the shaded areas prior to clinical and submit to the instructor at the beginning of
the clinical experience. The remainder of the form should be completed upon the completion of the clinical experience and
submitted with post clinical paperwork.
PATIENT ADMISSION DATA
Date of Patient Initials Age Sex Marital Level of Occupation Religion Ethnicity
Admission CP 84 M Status: education Retired Christianity non-hispanic
10/2/24 M HS
Interpreter? N/A
Allergies (Reaction): Past Medical History: afib,s/p pacer, HTN,HLD,hypothyroidism,gout, chest pain,
NKA CKD,CAD, anemia
Admitting DX: CHF
Vital Signs: T:97.8 OR P: 62 R:18, regular unlabored BP:150/80(bp trends Weight:178IB
high)
BMI:27.10
Apical HR:62 Oxygen Saturation: 96% 2L NC
ADVANCED DIRECTIVES
Living Will: Power of Attorney: Do Not Resuscitate (DNR) Order: FULL CODE
(Yes) No Yes (No) Yes (No)
SPECIAL CONSIDERATIONS/Orders
Ordered Diet Appetite Fluid Urinary catheter Fall Precaution Isolation (Type): Last BM Restraints (Type)
Healthy Heart Breakfast 100% Restrictions (Type & Size) YES N/A 10/3/24 N/A
Lunch 75% 1800 mL N/A, Voiding Standard normal
precautions formed
Blood Sugar: Frequency Activity: Intake and Wound Care Order Ordered Therapies: Daily weights, Fluid
N/A (Assistive Output? N/A restriction 1800mL,Tele
NO ACHS Devices) 0700 output
N/A 400mL
pt states “I Intake: few sips
do not have a of water with
walker or am meds
cane, I am 0930 output
able to walk 700mL
without”
Tube Feedings: N/A Intravenous Fluids
Type:____________ Route:__________ Primary IV
Type: Peripheral
Rate:__________ Goal rate:_________
Rate: NOT INFUSING, Capped and
Continuous____ Intermittent____ Flush____
flushed without difficulty/no
resistance, no s/s of
infiltration/phlebitis, dressing
clean/intact, no interventions needed
at this time
IV Location Distal LFA 18G
Pertinent Diagnostic Findings (imaging, stress tests, EKG, EEG, etc.)
CT chest : cardiomegaly
Tele : NSR
2
, Medications: List medications to be given (including possible PRN meds). Include dose and route.
● Eliquis 2.5mg Or
● cardidilol 12.6mg Or
● pravastatin 40 mg Or
● PRN : acetaminophen 650 mg Or Q 4hrs
Place all labs results on this page: Pay attention to pertinent labs and all abnormal results
● BNP 1,465
● Na 135
● Cl 96
● Co2 30
● bun 15, CR 1.60
● blood glucose 85
● wbc 9.4
● HBG 11 / HCT 34.3
● PLt 285
3
Department of Nursing
NUR 211/212
Adult Medical Surgical Clinical Packet
Section 1: Pre-Clinical Assessment
o Client Data Collection Form – To be completed during preclinical
o Pathophysiology
o Medical Analysis Cards
o Day of Care Map/Plan for clinical day
Section 2: Post Clinical
o Post clinical reflection – DEAL Method
o Submitted via email by 2355 on the day of the experience
Section 3: Concept Map (for a grade)
o Grading Rubric
o Preclinical Paperwork
o EBP Synopsis
o Nursing Process/Care Plan
o Evaluation of Care Provided and QSEN Competencies Met
1
,Section 1: Preclinical Assessment
Client Data Collection Form
Department of Nursing
Student Name:Hayley Farah Clinical SiteUNCS 6 Date: 10/2/24
Directions: The student is expected to complete the shaded areas prior to clinical and submit to the instructor at the beginning of
the clinical experience. The remainder of the form should be completed upon the completion of the clinical experience and
submitted with post clinical paperwork.
PATIENT ADMISSION DATA
Date of Patient Initials Age Sex Marital Level of Occupation Religion Ethnicity
Admission CP 84 M Status: education Retired Christianity non-hispanic
10/2/24 M HS
Interpreter? N/A
Allergies (Reaction): Past Medical History: afib,s/p pacer, HTN,HLD,hypothyroidism,gout, chest pain,
NKA CKD,CAD, anemia
Admitting DX: CHF
Vital Signs: T:97.8 OR P: 62 R:18, regular unlabored BP:150/80(bp trends Weight:178IB
high)
BMI:27.10
Apical HR:62 Oxygen Saturation: 96% 2L NC
ADVANCED DIRECTIVES
Living Will: Power of Attorney: Do Not Resuscitate (DNR) Order: FULL CODE
(Yes) No Yes (No) Yes (No)
SPECIAL CONSIDERATIONS/Orders
Ordered Diet Appetite Fluid Urinary catheter Fall Precaution Isolation (Type): Last BM Restraints (Type)
Healthy Heart Breakfast 100% Restrictions (Type & Size) YES N/A 10/3/24 N/A
Lunch 75% 1800 mL N/A, Voiding Standard normal
precautions formed
Blood Sugar: Frequency Activity: Intake and Wound Care Order Ordered Therapies: Daily weights, Fluid
N/A (Assistive Output? N/A restriction 1800mL,Tele
NO ACHS Devices) 0700 output
N/A 400mL
pt states “I Intake: few sips
do not have a of water with
walker or am meds
cane, I am 0930 output
able to walk 700mL
without”
Tube Feedings: N/A Intravenous Fluids
Type:____________ Route:__________ Primary IV
Type: Peripheral
Rate:__________ Goal rate:_________
Rate: NOT INFUSING, Capped and
Continuous____ Intermittent____ Flush____
flushed without difficulty/no
resistance, no s/s of
infiltration/phlebitis, dressing
clean/intact, no interventions needed
at this time
IV Location Distal LFA 18G
Pertinent Diagnostic Findings (imaging, stress tests, EKG, EEG, etc.)
CT chest : cardiomegaly
Tele : NSR
2
, Medications: List medications to be given (including possible PRN meds). Include dose and route.
● Eliquis 2.5mg Or
● cardidilol 12.6mg Or
● pravastatin 40 mg Or
● PRN : acetaminophen 650 mg Or Q 4hrs
Place all labs results on this page: Pay attention to pertinent labs and all abnormal results
● BNP 1,465
● Na 135
● Cl 96
● Co2 30
● bun 15, CR 1.60
● blood glucose 85
● wbc 9.4
● HBG 11 / HCT 34.3
● PLt 285
3
