Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Clinical objectives and competences

Nursing Care of Adult I (NURS 315)

Concepts are introduced in the classroom and related skills practice is provided in the nursing skills
laboratory and during simulated patient care experiences.

1. Perform complete history physical assessment of patients.

2. Perform appropriate nursing interventions to patients with selected acute and
chronic disorders.
3. Follow the unit protocols in performing procedures and administering
medications.
4. Identify, assess, and evaluate the nursing observations and actions indicated in
each disease or disorder of patients.
5. Apply the principles of history taking in the assessment process of individuals.
6. Determine subjective and objective data to validate findings.
7. Apply basic standards of documentation and reporting of health assessment
findings.
8. Apply principles of patient education in clinical settings
9. Use different communication skills to develop an effective therapeutic
relationship when conducting a heath assessment.
10. Given information relative to a client’s physical assessment, document and report
physical assessment.
11. Document problems and needs in individuals from data discovered during the
health history and physical examination utilizing health information technology.
12. Demonstrate health assessment competencies in performing health assessment
from head to toe.

Fundamentals clinical objectives:

First Objective: Perform in a safe and therapeutic manner as follow:

1- Medication Administration
2- Tube feeding
3- Tube care (Tracheostomy, Ostomy)
4- Initiating IV infusion
5- Wound Care
6- Changing Position
7- Maintain Patient Safety

2
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Second Objective: Create nursing care plan based on the assessment data and
findings for patient suffering from the following problems:
• Upper respiratory tract disorders
• Lower respiratory tract disorders (COPD, Asthma, TB, Pneumonia)
• Coronary Vascular Disorder (Atherosclerosis, Angina, AMI)
• Heart Disease (Heart Failure, Hypertension)
• Peripheral Vascular (DVT)
• Hematologic Function (Leukemia, thrombocytopenia)
• Endocrine (Diabetes mellitus)
• Upper GIT disorders (Peptic ulcer, Gastric disorder)
• Lower GIT disorder (intestinal obstruction, hernia, appendicitis, rectal disorder, hemorrhoids
Common liver, gallbladder disorder)
Third Objective: Perform the perioperative assessment and teaching accurately.
Preoperative
1- Informed Consent form
2- Physical Examination
3- Preoperative teaching
4- Using Spirometry
5- Wearing Anti embolic Stocks
Intraoperative (OR Room)
1- Scrubbing Nurse
2- Circulating Nurse
3- Creating a Sterile flied
Postoperative
1- Physical Examination (Vital Signs)
2- Wound assessment
3- Consciousness Assessment

3
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Adult Health Assessment Sheet

:Student's Name :Section
:ID :Date
Form Number :Instructor
:Clinical Area Hospital, Rehabilitation, Simulation :Unit/ Floor

1- Bio-socio-demographic data (6 0.5 each)

▪ … - :Patient's Initials

▪ Department: Nationality: Saudi ( ) Non-Saudi ( )

▪ Age: - ---------- Religion: Muslim ( ) Christian ( ) Others ( )
▪ Gender:- □ Male □ Female
▪ Marital status:-
□ Single □ Married □ Divorced □ Widow
▪ - :Level of education

□ Illiterate School □ Diploma □ University

▪ …- :Occupation

▪… - :Date of admission
▪ …- :Diagnosis
▪ …- :Name of operation
▪ …- :Date of operation
▪ …- :Post-operative days

2- Health history

2.1- Reason for Hospitalization: (1 score)

2.2- Chief/present Complain: (2.5, 0.5 Each)

o :Onset ( ) Sudden ) Gradual (
oDuration o ........... ....... Aggravating factors
oAlleviating factors
oAssociated manifestations

4
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Item Please circle If (yes) Specify

2.3- Past History (2.5, 0.5 Each)
Previous hospitalization No Yes
Associated diseases No Yes
Previous surgery No Yes
Allergies No Yes
Previous blood transfusion No Yes Type Amount Time
2.4- Family history (3.5, 0.5 Each)
Cancer No Yes
Hypertension No Yes
Diabetes Mellitus No Yes
Kidney disease No Yes
Asthma No Yes
Heart disease No Yes
Liver disease No Yes
Others No Yes
2.5- Lifestyle/health patterns/habits (5.5, 0.5 Each)
:Medication
- Prescribed No Yes
- Over counter No Yes
:Smoking
- Non-Smoker No Yes
- Smoker No Yes :Type No per day
- Passive smoker No Yes :No of years
- Quitter No Yes
:Alcohol intake No Yes
:Nutrition - Frequency ( meals/day)
- Likes and dislikes
- Amount of fluid intake L/day
Elimination - / Bowel frequency
- Urinary frequency /day
Sleep - Sleep hours: Day Night
:Level of activity - Independent ( )
- .……Partial independent ( ) Specify
- Dependent ( )
:Others

3- Physical examination
General appearance (2.5, 0.5 Each)
Consciousness: Conscious Altered *
* Patient's posture: Normal Scoliosis Kyphosis Lordosis
* Grooming: Tidy Untidy * Hygiene: Good Poor
* Weight: Normal Thin Obese
* Gait: Normal Abnormal

5
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Vital signs (5.5, 0.5 Each)

1. Temperature
2. Pulse: rate rhythm
3. Respiration: rate rhythm depth
4. :Blood pressure: value site
5. Pain: site severity radiation
increasing factors decreasing factors

No pain Worst

Item Please circle If (yes) Specify

Amount and distribution Normal Abnormal Brittle Alopecia
(Each 0.5 ,2.5)

of hair
Head

Presence of lice No Yes

Presence of dandruff No Yes
Scalp Intact Not intact Scratches Lesions
Others No Yes
Color Healthy Unhealthy Pale Cyanotic Yellow

Eye
Vision Normal Impaired Prosthesis R/L
Color Normal Abnormal Yellow
Others No Yes
Ear
Hearing Normal Impaired Prosthesis R/L
Others No Yes
Nose Congeste
Face (6.5, 0.5 Each)

Patency Patent /d
Obstructe
d
Position of nasal Normal Abnormal
septum
Others No Yes

Item Please circle If (yes) Specify

Mouth
Lips Normal Abnormal Moist Dry Cracked
Mucus membrane Normal Abnormal Ulcers Patches Dry
Bleeding
Teeth Intact Lost Denture Dental caries
Odor Absent Present
Tongue Normal Abnormal Ulcers Coated Dry
Others No Yes

6
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Jugular veins Flat Congeste

Neck(2.1.5
(Each 0.5 ,
d
Range of motion (ROM) Free Limited
Others No Yes
Inspection Barrel Kyphosis Funnel
- Shape of chest wall Normal Abnormal Pigeon
Chest movements - Equal Unequal
Using of accessory -
No Yes
muscles
Others - No Yes Oxygen therapy specify
(method: and liter )
Palpation
Chest expansion - Equal Unequal
Tenderness - No Yes
Lumps - No Yes
Chest (11, 1 Each)

Others - No Yes
Percussion Flatness Dullness
Percussion sound - Resonan Abnormal Hyperresonant Tympany
t Others
Auscultation
Air entry - Bil-equal diminished
Breath sounds - Normal Abnormal Wheezing Crackles
Rhonchi
Heart sound - Normal Abnormal Murmurs Gallop Snaps
Apical pulse - Rate

- Rhythm

Others - No Yes Cough: dry ( ) wet ( )

Chest pain Orthopnea
Paroxysmal nocturnal dyspnea
Dyspnea (grade .......... )
Item Please circle If (yes) Specify
Inspection
- Shape Normal Abnormal Distension Ascites Hernia
Abdomen (3, 0.5 Each)

Ostomy
- Skin integrity Intact Abnormal Scars Rashes
Auscultation
- Bowel sounds Present Hypoactive Hyperactive
Absent
Enema
Palpation Flat Abnormal Splenomegaly Hepatomegaly
General palpation - Lax Tenderness Mass Firm
Soft

7
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

- Feeding Oral Others NPO Anorexia Nausea

NGT _ Gastrostomy
Jejunostomy _ _ TPN
- Others No Yes Anorexia Pain Constipation
Diarrhea Vomiting Hematemesis
Melena Incontinence
Urine Normal Abnormal Dysuria Polyuria Anuria
Frequency Oliguria Urgency
Hematuria Incontinence
Urinary catheterization Nocturia

Skin color Normal Abnormal Cyanosis Pale Yellowish

Skin integrity Intact Abnormal Scars Lesion
Upper & Lower Extremities (5.5, 0.5

.Skin temp Warm Abnormal Hot Cool Moist

Skin turgor Elastic Inelastic Dry
Sensation Normal Abnormal Paresthesia Numbness
Varicose veins No Yes Site
(Each

Edema No Yes Site Type Degree

Nails color Normal Abnormal
Nails shape Normal Abnormal Clubbing Brittle
Capillary refill  sec 3 Abnormal  sec 3
Joints Free Limited Swelling Deformed Redness
Others No Yes Amputation Site

Cervical Non Palpable

Lymph Nodes
(Each 0.5 ,1.5)

palpable
Axillary Non Palpable
palpable
Femoral Non Palpable
palpable
Item Please circle Specify the alteration
Temporal Present Absent
Peripheral Pulse (4, 0.5

Carotid Present Absent

Brachial Present Absent
(Each

Radial Present Absent

Femoral Present Absent
Popliteal Present Absent
Posterior Tibial Present Absent
Dorsalis pedis Present Absent
(score

Presence of Absent Present Location

Other

1)
s

pressure ulcers Stage

8
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

▪ Location: use "X" to mark wound site on body diagrams

( )

▪ :Type
 Closed  Clean
 Open  Clean contaminated
Wound Assessment (3.5, 0.5 Each)

 Contaminated
 Infected

▪ :Skin surrounding wound Intact □ Not intact □

:If not intact, specify -

▪ :Open wound base  Epithelial

 Granulation
 Slough
 Necrotic

▪ Presence of wound drain or tube: Yes No

-:If yes, specify -

▪ Type: Open system Closed system

▪ Wound exudates/drainage
Type - Bloody □ Serosanguineous □ Serous □ Purulent □
Amount - None □ Small □ Moderate □ Large □
Odor - None □ Foul □

9
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

4. :Laboratory & Diagnostic findings

a. Laboratory studies (4 Each)
Name of test value Name of test value

b. Diagnostic studies (1.5, 0.5 Each)

Name Date Result

5. List of current medications (5 Each)

Name Classification Name Dose Route Time Frequency

10
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Nursing Progress Notes

:Date Nurses’ Notes & Name
(All Notes should be signed by the nurse) (6 Each) Signature
:Time

Patient’s Name:
Age:
Sex:
Nurses’ Progress Notes
Nationality:
:Ward
:MRN

* List the patient's problems (Nursing Diagnosis Form) (6 scores)

1. …………………………………………………………………….
2. …………………………………………………………………….
3. …………………………………………………………………….
4. …………………………………………………………………….
5. …………………………………………………………………….
6. …………………………………………………………………….
7. …………………………………………………………………….

11
 Bachelor of Science in Nursing Program (BSNP)

SASCED-L: 645 ASCED-P: 09130202

Nursing Care Plan (ungraded)

Nursing diagnosis Goal Nursing interventions (Assessment, Evaluation Total
(Actual and potential-priority order) (Expected outcome) care, health teaching) Rational Score =1
Total Score = 2 Total Score = 1 Total Score = 6
Nursing diagnosis 1: Short Term Goal: Assessment: ---------------------------------------------- -------------------
-----------------------------------

AMB:( --------------------------------
) Care:
SD:

Long Term Goal:

-----------------------------------
----------------------------- Health/Family Teaching:
OD:

Nursing diagnosis 1: Short Term Goal: Assessment: --------------------------------------------- -------------------

-----------------------------------

AMB:( --------------------------------
----------------------) Care:
---------------------------------------------- -------------------
SD: Long Term Goal:
-----------------------------------

----------------------------- Health/Family Teaching:

OD: