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: Respiration CVS: Breasts: Abdomen: Muscularskeletal: Patient Present condition: fair, stable, ill Medical/Surgical Management: Diet: IVF/heploc: Activity: Foleys cath: V/S : T= P= R= BP= Glucose: Meds: casts/traction: Labs: O2 : surgical procedures: Xrays/Scans drains : IVF/lines: Drains: Pain/comfort: on a pain scale of 0-10

Physio:

Others

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