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Adult Nursing Practicum -Nurs 229

Verbal Report Format

Students must be able to present this verbal report on their patients during each clinical

rotation except for OT & Dialysis sessions

Name and age:

Admission date:

Medical HX Surgical HX

Family History:

Social History:

Reason for admission/Presenting Problems

Client present to PMH with c/o:

Current Diagnosis/Diagnoses:

Concurrent Diagnosis/Diagnoses:

On Physical Assessment the clients

Neuro:

Dressings:

Skin, hair, nails: IVF/lines:

Respiration Drains:

CVS: Pain/comfort: on a pain scale of 0-10

Breasts:

Abdomen:

Muscularskeletal:

Patient Present condition: fair, stable, ill

Medical/Surgical Management:Diet: IVF/heploc: Physio:

Activity: Foleys cath:

V/S : T= P= R= BP= Glucose:Meds: casts/traction:

Labs:

O2 : surgical procedures:Xrays/Scans drains : Others

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General Nursing Management

Problem/need (Maslow): at least (2)

Priority NANDA nursing diagnoses at least (2)

Dx:

Goal:

Short term

Long term

Interventions:1Monitor and record V/S Q4hrly

2Assess

3Therapeutic

4Doctor ordered

5 Education or diagnostics