Download Marion Technical College Nursing Education Department Nursing

Marion Technical College
Nursing Education Department
Nursing 1021
Database
Assessment Booklet
Assessment Booklet
Rev. 12/16/15
1
DIRECTIONS ON HOW TO COMPLETE BOOKLET
1. Prior to your first clinical day:

Obtain patient assignment from hospital.

Complete pages 3, 4, 5, and Medication List (pg. 14-17) using patient’s
chart.
2. After working with your patient on day 1:
 Complete rest of the booklet
3. Turn completed booklet in the following Monday with rest of homework.
2
Student Name: _____________________ Date(s) of Clinical Assignment:__________
Pt. Room # ____
GENERAL INFORMATION AND HEALTH HISTORY
Nursing Data Base
Age
Pt. Initials
Admission Date/Time
Sex
Wt
Ht
SMWD
Race
Admitted From:
Primary Physician
History Obtained From
Consulting Physician(s)
Diagnoses (pertinent to this admission):
Surgeries pertinent to this admission:(Date/procedure)
Reason for Admission in Patient’s Own Words

Reason for this Hospitalization (from History & Physical)

Previous Hospitalizations (include past surgeries as well as past medical hospitalizations):




Smoker
N.A.


_____PPD
Ineffective
Health
Maintenance
Ineffective self
Health
management
Noncompliance
Other:
Alcohol ______ drinks per day/week (circle)
N.A.
Patient’s Medical History:




Diabetes
Hypertension
Heart Disease
Tuberculosis




Respiratory Dis.
Hepatitis
Vision Disorder
Seizure Disorder







Cancer
GI Disease
Blood Disorder
Others:
Kidney Disease
Thyroid Disease
Neuromuscular



Mental Illness
Arthritis
Sexual Diseases
Family Medical History: √ diseases; if deceased, state what they died of (last column)
HTN
CVA
Heart Dis.
Cancer
Diabetes
Alcoholism
Mental Ill.
Died of:
Mother Hx
Father Hx
Sibling Hx
Sibling Hx
Medications patient is currently taking:
Name
 No Known Allergies
 Allergies (include food, medications and patient’s reaction):
___________________________________________
___________________________________________
Dose/
Frequency
Name
3
Dose/
Frequency
DIAGNOSTIC TESTS
Mark Patient Lab Results that are lower () or higher () than normal values.
See Trends of Vital Signs and Labs Sheets (ie – the Trending Sheet)
Complete any labs below that are ordered for this patient but are not included on the Trending Sheet
Labs:
Date
Lab
Results
Normal Values
Hematology
See Trending Sheet under CBC Results.
Chemistry
Other Blood work that is considered “Chemistry” includes: sodium, potassium, chloride, Co2, glucose and
accuCheck. See Trending sheet for these values.
Labs:
Arterial
Blood
Gases
Coagulation
Studies
Date
Lab
Results
9.0 – 10.5 mg/dl
3.45 mg/dl
0-35 U/L
4-36 U/L
100-190 U/L
(F)30-135 U/L; (M)55-170 U/L
< 200 mg/dl
Fe > 55 mg/dl; M > 45 mg/dl
60-180 mg/dL
7.35-7.45
35-45 mm Hg
80-100 mm Hg
95% - 100%
21 – 28 mEq/L
0 + 2 mEq/L
Calcium
Phosphorous
AST (SGOT)
ALT (SGPT)
LDH
CPK
Cholesterol
HDL (High Density Lipoprotein)
LDL (Low Density Lipoprotein)
PH
PCO2
PO2
O2 Saturation
HCO3
Base Excess
See Trending Sheet for PT, PTT, and INR
Urinalysis See Trending Sheet for Color, Sp. Gr., RBC, WBC
Source:
C&S
Other:
Normal Values
Labs:
Date
Lab
Results
4
Negative
Normal Values
X-RAY AND SPECIAL TEST RESULTS
Record physician’s Impression only (usually found toward end of test results in chart).
TEST
DATE OF
TEST
RESULTS
GROWTH AND DEVELOPMENT FUNCTION Stage
Check appropriate developmental stage for your patient. (See last page of Assessment Booklet for Developmental Tasks
handout.)








Birth to 1 year
1 - 3 years
4 - 5 years
6 - 11 years
12 - 18 years
20 - 40 years
40 - 65 years
>65 years
Infant
Toddler
Preschool
School Age
Adolescence
Young Adulthood
Middle Adulthood
Maturity (Old Age)
Trust vs. Mistrust
Autonomy vs. Doubt and Shame
Initiative vs. Guilt
Industry vs. Inferiority
Identity vs. Identity Diffusion
Intimacy vs. Isolation
Generativity vs. Stagnation
Integrity vs. Despair and Disgust
Based on your patient’s stage checked above, list 5 tasks in column one that your patient should be achieving. Following
your clinical experience, complete column two by stating whether or not these tasks are being met and give data.
TASKS
1.
Is task currently being met? Record patient data
that helped you to reach this conclusion.
□ yes □ no
2.
□ yes □ no
3.
□ yes □ no
4.
□ yes □ no
5.
□ yes □ no
5
NURSING ASSESSMENT
VITAL SIGNS: BP________ p _______ R_______ T_______
COMFORT AND REST FUNCTION - (Sleep/Rest/Pain/Comfort):
Sleep
Pain Assessment
 No problems
 No pain currently
 Time of last pain med:
 Difficulty staying
 Pain:
_______________
asleep
o Location:
 Difficulty falling asleep
 Medication(s) used:
 Not rested after sleep
o Scale of 1-10:
_________________
 What helps you
______
sleep?
o Sharp
o Dull
o Ache
o Constant
o Other:
(√appropriate N. Dx)
 Insomnia
 Acute Pain
 Chronic Pain
 Sleep Deprivation
 Other:
MEDICATIONS:
SUBJECTIVE/NONVERBAL DATA:
____________________________________________________________________________________________________
___________________________________________________________________________
SENSORY PERCEPTUAL FUNCTION - (Neurological):
Oriented to:
Level of
Pupils
Consciousness
 Person
 Alert
 PERLA
 Place
 Stuporous
 Other:
 Time
 Semi________
 Event
comatose
________
 Other
 Comatose
 Combative
Pupil Size:
 Anxious
 Right: ______
 Confused
 Left: _______
Visual Impairment





None
Wears Glasses
Contacts
Blind Right Eye
Blind Left Eye
Speech Impairment
Hearing Impairment













None
Hard of Hearing
Deaf Right Ear
Deaf Left Ear
Hearing Aid Right Ear
Hearing Aid Left Ear
Pain/Discomfort – Ear
Other:

Language Barrier:

Yes (describe):

No






Other Neuro
Symptoms
Headache/Pain
Tingling
Seizures
Numbness
Tremors
Motor
Disturbance
(Describe):


None
Slurring
Mute
Stutters
Cannot
Express
Cannot
Understand
Tracheostomy
Laryngectomy
(√appropriate N. Dx)

















Risk for Falls
Impaired Verbal
Communication
Acute Confusion
Risk for Acute
Confusion
Chronic Confusion
Risk for Injury
Deficient Knowledge
(specify)
Impaired Memory
Unilateral Neglect
Acute Pain
Chronic Pain
Risk for Peripheral
Neurovascular
Dysfunction
Disturbed Sensory
Perception: auditory
Disturbed Sensory
Perception: tactile
Disturbed Sensory
Perception: vision
Disturbed Thought
Process
Other:
MEDICATIONS:
SUBJECTIVE/NONVERBAL DATA:________________________________________________________________
__________________________________________________________________________________________
6
FLUID GAS TRANSPORT FUNCTIONS (Cardiovascular):
Blood Pressure
(__________)
 Hypertension
 Pacemaker
 Chest Pain
Apical Pulse
(________)
 Regular
 Irregular
 Strong
 Weak
Radial P
(________)
 Regular
 Irregular
 Strong
 Weak
 Thready
Lower Extremities
Upper Extremities


Capillary Refill
 Brisk < 3
secs
 Sluggish
>3 secs
Nailbeds pink
LABS
RBC:_____











Hct:______
Hgb: _____

Platelets:_____
Pink
Pale
Cyanotic
Flushed
Mottled
Ulcers
Brown patching of lower legs
Color of feet when dependent:
_____________
Varicose veins
Leg pain with/ without activity
Capillary Refill
o Brisk < 3 secs
o Sluggish> 3 secs
DP pulses:
o Palpable
o Non-palpable
Cholesterol:_____




Temperature
(_________)
Oral
Tympanic
Rectal
Axillary
Edema




(√appropriate N. Dx)

Location:
_________
Pitting
Nonpitting
Absent


IV Therapy

IV #1:
Solution/rate:__________________
Location: _____________________
Appearance of site:


IV #2:
Solution/rate:__________________
Location: _____________________
Appearance of site:




PCA: Medication______________
 Intermittent dose: _____________
- Lockout interval: _____________
 Basal rate: ___________________
Location: ______________________
Appearance of site:




Epidural:
Medication/rate:_________________
Appearance of site:
HDL:____
Decreased Cardiac
Output
Risk for deficient
Fluid volume
Deficient Fluid
volume
Risk for imbalanced
Fluid volume
Excess Fluid volume
Readiness for
enhanced Fluid
balance
Hypothermia
Hyperthermia
Risk for Infection
Ineffective
Thermoregulation
Ineffective Tissue
Perfusion: Cerebral
Ineffective Tissue
Perfusion: Systemic
Ineffective Tissue
Perfusion: Peripheral
Other:
MEDICATIONS:
LDL: ________
TPN @
cc/hr
Location: _____________________
Appearance of site:
CPK: _______
PT: ______
PTT: ______
Salinelock location:_______________
INR: ______
Appearance of site:
Other:
SUBJECTIVE DATA:___________________________________________________________________________
__________________________________________________________________________________________
FLUID GAS TRANSPORT FUNCTIONS (Respiratory):
Cough



Productive
Nonproductive
Sputum color:

Suctioning
Arterial Blood
Gases
PO2:
PCO2:
pH:
HCO3:
Chest





Symmetrical
Assymmetrical
Chest tube L
Chest tube R
Spirometer
_______ ml
high
Respiratory
Effort









Breath
Sounds/
Location
 Clear
Bilaterally
 Equal
Bilaterally
 Crackles
Rate:
______
Normal
Dyspnea
Orthopnea
Tracheostomy
 Wheezes
Oxygen
_____ L/min  Diminished
Cannula
Mask
 Other:
O2 Sat:
________
Isolation
 Respiratory
 Protective
 Other:
(√appropriate N. Dx)




Presence of:
 Kyphosis


Activity Intolerance
Risk for Activity
Intolerance
Ineffective Airway
Clearance
Ineffective Breathing
Pattern
Risk for Infection
Other:
MEDICATIONS:
SUBJECTIVE DATA: __________________________________________________________________________________
____________________________________________________________________________________________________
7
ELIMINATION FUNCTON (Gastrointestinal):
General
Appearance


Well-nourished
Malnourished
Abdominal Assessment
Bowel Sounds:
 Active
 Hyperactive
 Hypoactive
Ostomies:



Colostomy
Jejunostomy
Other:
Abdomen:
 Soft
 Firm
 Tender
 Non-tender
 Distended
 Flat
 Round
Bowel Movement









(√appropriate N. Dx)
Passing Flatus
Last BM _____
Normal BM
Constipated
Diarrhea
Blood in stool
Pain with defecation
Hemorrhoids
Incontinent of BM






Bowel Incontinence
Constipation
Risk for Constipation
Diarrhea
Toileting Self-Care deficit
Other:
MEDICATIONS:
SUBJECTIVE DATA:____________________________________________________________________________________________
________________________________________________________________________________________________________________
ELIMINATION FUNCTION (Genitourinary):
Assessment
Urine color:
 Clear
 Cloudy
 Hematuria
 Straw
 Dark amber
 Other:

Bladder
Distention
Dialysis:
 Peritoneal
 Kidney
URINALYSIS
Color: ________
Specific Gravity:
_____________
RBC: ________
WBC: _______
Urination:
 No problems
 Nocturia
 Incontinent
 Frequency
 Urgency
 Burning
 Retention
Catheter type:
 Foley
 Suprapubic
 Urostomy
 3-way: post
TUR
Intake
Day 1: ______
Day 2: ______
Day 3: ______
Total: _______
Output
______
______
______
______
Analysis of Intake and Output
Compare intake to output and state if
this finding is, or is not, within normal
limits for your patient and why, or why
not:












(√appropriate N. Dx)
Deficient Fluid volume
Excess Fluid volume
Risk for Deficient Fluid volume
Risk for Imbalanced Fluid volume
Infection
Risk for Infection
Toileting Self-care deficit
Impaired Urinary elimination
Stress Urinary incontinence
Urge Urinary incontinence
Urinary retention
Other:
MEDICATIONS:
LABS
Na+: ______
K+: _______
Cl-: _______
Co2:______
BUN: ______
Cr: ________
SUBJECTIVE DATA:___________________________________________________________________________________________
_______________________________________________________________________________________________________________
8
NUTRITION FUNCTION (Nutrition / Metabolic):
Weight/Height
Diet




Weight: _______
Height: _______
*BMI: _______




* Wt/lbs x 703
(Ht/inches) 2
Regular
Clear liq
Full liq
ADA
______cal
Low Na
Renal
Cardiac
Other:
Check one:
 Underweight
< 18.5
 Normal
18.5 – 24.9
 Overweight
25-29.9
 Obese
30 and above
Tube Feeding





Assessment
Nasogastric
Gastric
Jejunostomy
Type:
______________
Rate:
_______cc/hour
LABS
Blood glucose: _____
Accucheck: ________
Calcium: __________
Phosphorous: _____
SGOT: ________
SGPT: ________
LDH: _________
Albumin: ________
Prealbumin: _______









Indigestion
Vomiting
Nausea
Full feeling in
throat
Mouth sores
Choking
Difficulty
swallowing
Difficulty
chewing
Most recent
accucheck:
__________









(√appropriate N. Dx)
Risk for Aspiration
Risk for unstable blood Glucose
Imbalanced Nutrition less than
body requirements
Imbalanced Nutrition more than
body requirements
Risk for Imbalanced Nutrition
more than body requirements
Impaired Oral mucous
membrane
Feeding Self-Care deficit
Impaired Swallowing
Other:
MEDICATIONS:
SUBJECTIVE DATA:
Describe any recent gain or loss of weight:__________________________________________________________________
Describe any recent changes in appetite/eating patterns________________________________________________________
Other Subjective Data: _________________________________________________________________________________
PROTECTIVE FUNCTION (Hygiene, Skin, Integumentary):
Skin Color
Isolation







normal
/race
pale
flushed
cyanotic
jaundice
other:
Temperature
 warm
 cool
 hot
 Condition
 dry
 moist


Wound/sk
in
MRSA
Other:
Abnormalities
Mark any
abnormal
areas on
figures shown
below:
 no open areas
 pressure area
present
decubitus present
bruise present
abrasion present
skin tear present
lesions present
scars present
other:
_____________
 lentigo
 Hx. of skin
cancers







Wound Assess.
Type of Wound:
________________
Location: _______
________________
 Dry
 Staples/sutures
intact
 Wound
approximated
 Redness
 Edema at
wound site
If Decubitus ulcer:
 Stage:______
 Treatment:
(√appropriate N. Dx)
 Latex Allergy
response
 Risk for Latex
Allergy response
 Infection
 Risk for Infection
 Impaired Skin
Integrity
 Risk for Impaired
Skin Integrity
 Impaired Tissue
Integrity
 Other:
MEDICATIONS
Skin Turgor
 Good
 Fair
 poor
SUBJECTIVE DATA:__________________________________________________________________________
__________________________________________________________________________________________
9
ACTIVITY/MOBILITY/MOVEMENT FUNCTION (Musculoskeletal):
Mobility
Status
 Ambulatory
 Assist
 Transfer
with assist
 Bedrest
 Trapeze
Bathing:
 Self
 Assist
 Complete
LAB
Calcium: _____
Phosphorous:
____________
Assistive
Devices
 None
 Cane
 Wheelchair
 Walker
 Prosthesis
 Crutches
 Pillows: #
Limitations:





None
Weakness
Restriction
due to
surgery
Fatigue
Paralysis:

Other:
Pain:
 Location: ________________
 Cramping
 Spasms
 Tremors
 Joint Stiffness
 Swelling
 Limited joint ROM
 Presence of Kyphosis
 Gait disturbance:
____ Yes ____ No
Muscle
Right
Grips
 Strong
 Weak
Foot Push
 Strong
 Weak
Strength
Left
Grips
 Strong
 Weak
Foot Push
 Strong
 Weak
Amputation:
Location:
Devices:
 CPM
 TED
hose
 SCD
(Blue
wrap)
 Traction
(√appropriate N. Dx)
















Activity intolerance
Risk for Activity intolerance
Fatigue
Impaired bed Mobility
Impaired physical Mobility
Impaired wheelchair Mobility
Acute Pain
Chronic Pain
Risk for Peripheral
neurovascular dysfunction
R/T DVT
Bathing/hygiene Self-care
deficit
Dressing/grooming Self-care
deficit
Toileting Self-care deficit
Ineffective Tissue perfusion
Impaired Transfer ability
Impaired Walking
Other:
MEDICATIONS:
Describe:
SUBJECTIVE DATA:_____________________________________________________________________________________________
_________________________________________________________________________________________________________________
GROWTH AND DEVELOPMENT FUNCTION (Reproductive): MALE
Assessment:
Erection Inability
Disease/Symptom
Testicular Exam















Discharge
Tenderness
Pain
Mass
Penile Implant
Meds (Viagra)
No problems
Needs Information
STD hx
Itching
Other:
No problems
Performs monthly
Needs information
No problems






(√appropriate N. Dx)
Disturbed Body image
Deficient Knowledge
(specify)
Ineffective Role
performance
Sexual dysfunction
Ineffective Sexuality
patterns
Other:
MEDICATIONS:
SUBJECTIVE DATA:_____________________________________________________________________________________________
10
GROWTH AND DEVELOPMENT FUNCTION (Reproductive): FEMALE
Pregnancies





Assessment
If child-bearing age,
is patient currently
pregnant?
NA _____ yes ____
Gravida (how many
pregnancies):______
Number of children:
___________
Abortions:
_________
Last menstrual
period (LMP):
___________
 Abnormal
bleeding
 Abnormal
discharge
 Menopause
at:_______
 Hx of Sexually
Transmitted
Infections
Breast Exam





No lumps
If lump is
present,
describe:
Performs
monthly
Needs info.
Check () if
applicable
Pain with:
 Intercourse
 Menstruation
(√appropriate N. Dx)


Disturbed Body image
Deficient Knowledge
(specify)
Ineffective Role
performance
Sexual dysfunction
Ineffective Sexuality
patterns
Other:

Contraception
 Currently using


Experiencing:
 PMS
 Hot Flashes
 Other
symptoms of
menopause
(list):

MEDICATIONS:
SUBJECTIVE DATA:_____________________________________________________________________________
GROWTH AND DEVELOPMENT FUNCTION
Complete 2nd column of Developmental Task Achievement on page 5.
PSYCHO/SOCIAL/CULTURAL/SPIRITUAL FUNCTION
Role Relationships:
Home Environment
 Lives with
spouse
 Lives
alone
 Lives
w/family
 Other
(√appropriate N. Dx)
Subjective Data:
Who do you rely on for emotional support (check all that are applicable)?
 Spouse
 Family
 Friend
 Self
 Other:

How does your illness/hospitalization affect your family/significant others? Describe:










11
Impaired verbal
Communication
Dysfunctional Family
Processes
Interrupted Family
Processes
Anticipatory Grieving
Complicated Grieving
Risk for complicated
Grieving
Impaired Parenting
Risk for impaired
Parenting
Social Isolation
Impaired Social
Interaction
Other:
PSYCHO/SOCIAL/CULTURAL/SPIRITUAL FUNCTION (Continued)
Psycho-Social Behavior:
Subjective Data:
Describe any recent changes you have had in your life
(i.e., job, move, divorce, death, surgeries, abuse, etc.):
How do you feel you are dealing with stressors associated with this change?
(Describe using patient’s words):
What concerns you most about your hospitalization? (Describe using patient’s
words):
Does your illness and/or hospitalization affect how you feel about
yourself? (Describe using patient’s words):




















(√appropriate N. Dx)
Anxiety
Disturbed Body Image
Impaired verbal Communication
Interrupted Family Processes
Fear
Complicated Grieving
Hopelessness
Risk for Loneliness
Impaired Parenting
Powerlessness
Risk for Powerlessness
Ineffective Role performance
Chronic low Self-esteem
Situational low Self-esteem
Social Isolation
Impaired Social interaction
Chronic Sorrow
Risk for other-directed Violence
Risk for self-directed Violence
Other:
MEDICATIONS:
Values / Beliefs/ Spiritual
Subjective Data:
(√appropriate N. Dx)
Does religion or spirituality play a part in your life:  yes
 no
- If yes, in what way does it play a part? __________________________________________
__________________________________________________________________________



Does your religion or spiritual beliefs affect medical treatment (i.e., receiving blood, last rites, etc)?
 yes (describe in what way: __________________________________________________)
 no
Is your pastor (or priest, rabbi, spiritual leader, etc.) aware of your hospitalization?  yes
-
If no, do you wish for this person to be notified?
 yes
 no
 no
Do you have a special religious request at this time?  yes (state request in the space below)
 no
12

Spiritual distress
Risk for Spiritual
distress
Readiness for
enhanced Spiritual
well-being
Other:
PROTECTIVE FUNCTION (Education/Discharge Planning):
Assessment of Patient’s Ability to Learn
Identification of Education Needs
Identifies knowledge about
health problem:
 Yes: describe this knowledge:
When identifying need(s), be
specific. Examples:
 Disease  Diabetes
 Medications:  Insulin

 Medications:
No
(√appropriate N. Dx)
Caregiver role strain
Risk for Caregiver
role strain
 Ineffective Health
maintenance
 Impaired Home
maintenance
 Deficient Knowledge
(specify)
 Noncompliance


Exhibits ability to learn:
 Yes: (include objective and/or subjective data to
validate your findings):
 Disease information:


No, describe barrier to learning:
 Post-operative care:
MEDICATIONS:

Literacy level – Highest grade achieved:
___________
 Other, describe
List at a minimum one
medication your patient is
taking that effects
learning and list what this
effect is:

Exhibits one or more of the following (include
objective and/or subjective data to validate your
findings):
 Anxiety:_____________________________
____________________________________
 Depression:__________________________
____________________________________
 Confusion:___________________________
____________________________________
 Pain:_______________________________
____________________________________
 Other:______________________________
____________________________________
Primary Care Giver when patient
returns home:


Exhibits motivation to learn:
 Yes: describe behaviors to indicate this motivation:

No: explain why you chose this answer:
Exhibits readiness to learn:
 Yes: describe behaviors to indicate this readiness:

No: describe behaviors to indicate lack of readiness:
List environmental variables that may affect learning
(i.e., noisy, too dark, cold, etc.)
13
Self
Other:
______________________
Other:
Braden Scale for Predicting Pressure Sore Risk
Sensory Perception: Ability to respond meaningfully to pressure-related discomfort
1.
2.
3.
4.
SCORE
Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR
limited ability to feel pain over most of body surface.
Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a
sensory impairment which limits the ability to feel pain or discomfort over half of the body.
Slightly Limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has some
sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture: Degree to which skin is exposed to moisture
SCORE
1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time
patient is moved or turned.
2. Very Moist: Skin is often but not always moist. Linen must be changed at least once a shift.
3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely Moist: Skin is usually dry: linen requires changing only at routine intervals.
ctivity: Degree of physical activity
SCORE
1. Bedfast: Confined to bed.
2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair
or wheelchair.
3. Walks Occasionally: Walks occasionally during the day, but for very short distances, with or without assistance. Spends
majority of each shift in bed or chair.
4. Walks Frequently: Walks outside the room at least twice and inside room at least once every 2 hours during waking hours.
Mobility: Ability to change and control body position
SCORE
1. Completely immobile: Does not make even slight changes in body or extremity position without assistance.
2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant
changes independently.
3. Slightly Limited: Makes frequent though slight changes in body or extremity position independently.
4. No Limitation: Makes major and frequent changes in position without assistance.
Nutrition: Usual food intake pattern
SCORE
1. Very Poor: Never eats a complete meal. Rarely eats more than 1/3 of food offered. Eats 2 servings or less of protein
(meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR is NPO and/or
maintained on clear liquids or IV for more than five days.
2. Probably Inadequate: Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake
includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR receives less
than optimum amount of liquid diet or tube feeding.
3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day.
Occasionally will refuse a meal, but will usually take a supplement if offered, OR is on a tube feeding or TPN regimen,
which probably meets most of nutritional needs.
4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy
products. Occasionally eats between meals. Does not require supplementation.
Friction and Shear
SCORE
1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is
impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.
Spasticity, contractures, or agitation leads to almost constant friction.
2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent
against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but
occasionally slides down.
3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely.
Risk Level
19 – 23 Not at risk
NPO: Nothing by Mouth
Total Score:
15 – 18 Low Risk
Total Points Possible: 23
IV: Intravenously
13 – 14 Moderate Risk
10 – 12 High Risk
Risk Predicting Score: 16 or Less
TPN: Total parenteral nutrition
<9
Very High Risk
This handout adapted from required textbook, Taylor, Lillis, et. al. (2011). Fundamentals of Nursing. Wolters Kluwer/Lippincott Williams & Wilkins,
p. 936. (From: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission. All rights reserved.)
3 or 4 = Moderate to Low Impairment
14
MEDICATION LIST
For clinical prep: complete the first 7 columns for scheduled meds and frequent PRN’s given during the time you are on the unit. For homework, complete these columns
for the rest of the meds including IV’s, IVPB’s, and other PRN’s. Complete the “effectiveness” column for all drugs including the ones you did not give for homework.
Medication Name
(generic and
Trade)
1. Safe
Dosage
2. Patient
Dosage,
Route,
Frequency
Classification &
Indication for
THIS pt.
Mechanism
of
Action
•
Major Side
Effects
Nursing Considerations
Drug to drug or drug to food
interactions
15
What you would tell
patient about this
drug
Was this drug
effective for your
patient?
(complete after
clinical and
give data to support)
MEDICATION LIST
For clinical prep: complete the first 7 columns for scheduled meds and frequent PRN’s given during the time you are on the unit. For homework, complete these columns
for the rest of the meds including IV’s, IVPB’s, and other PRN’s. Complete the “effectiveness” column for all drugs including the ones you did not give for homework.
Medication Name
(generic and
Trade)
1. Safe
Dosage
2. Patient
Dosage,
Route,
Frequency
Classification &
Indication for
THIS pt.
Mechanism
of
Action
•
Major Side
Effects
16
Nursing Considerations
Drug to drug or drug to food
interactions
What you would tell
patient about this
drug
Was this drug
effective for your
patient?
(complete after
clinical and
give data to support)
MEDICATION LIST
For clinical prep: complete the first 7 columns for scheduled meds and frequent PRN’s given during the time you are on the unit. For homework, complete these columns
for the rest of the meds including IV’s, IVPB’s, and other PRN’s. Complete the “effectiveness” column for all drugs including the ones you did not give for homework.
Medication Name
(generic and
Trade)
1. Safe
Dosage
2. Patient
Dosage,
Route,
Frequency
Classification &
Indication for
THIS pt.
Mechanism
of
Action
•
Major Side
Effects
17
Nursing Considerations
Drug to drug or drug to food
interactions
What you would tell
patient about this
drug
Was this drug
effective for your
patient?
(complete after
clinical and
give data to support)
MEDICATION LIST
For clinical prep: complete the first 7 columns for scheduled meds and frequent PRN’s given during the time you are on the unit. For homework, complete these columns
for the rest of the meds including IV’s, IVPB’s, and other PRN’s. Complete the “effectiveness” column for all drugs including the ones you did not give for homework.
Medication Name
(generic and
Trade)
1. Safe
Dosage
2. Patient
Dosage,
Route,
Frequency
Classification &
Indication for
THIS pt.
Mechanism
of
Action
•
Major Side
Effects
18
Nursing Considerations
Drug to drug or drug to food
interactions
What you would tell
patient about this
drug
Was this drug
effective for your
patient?
(complete after
clinical and
give data to support)
Developmental Tasks
Personality Development and Developmental Tasks
AGE
STAGE OF PERSONALITY
DEVELOPMENT
1 mo to 1 yr
Basic Trust vs. Mistrust
Infant
(foundation for all subsequent
achievement)
1-3 years
HAZARDS TO
ACHIEVEMENT
DEVELOPMENTAL TASKS
Abuse, neglect, deprivation
of love.
Learn to eat solids.
Autonomy vs. Shame and Doubt
(development of the individual self)
Anything which causes
feelings of inadequacy.
Learn to walk.
Learn to use fine muscles.
Accomplish toilet training.
Learn to communicate.
Initiative vs. Guilt
(conscience develops)
Rigid moral attitudes, any
interference with reality
testing.
Independent in self-care.
Learn sexual role identity.
Form reality concepts.
Internalize concepts of right and wrong.
Learn to identify with family members and
others.
Industry vs. Inferiority
(develops pleasure in work
completed)
Excess competition.
Experience with failure.
Personal limits resulting in
poor work habits.
Acquire game skills.
Learn to relate positively with peers.
Build a wholesome self-concept.
Refine communication skills.
Adolescence
Identity vs. Role Confusion
(acquiring a sense of identity; role
clarification)
Any interference with
development of identity
and role standards.
Form peer relationships.
Respond to an appropriate sexual role.
Attain emotional independence.
Achieve a sense of economic indepen-dence.
20-40 years
Intimacy vs. Isolation
Lack of personal identity.
Achieve independence from parents.
Establish intimate relationships.
Choose an occupation or career.
Enjoy the present but build for the future.
Generativity vs. Stagnation
(productivity and creativity for
others as well as self)
Failure to master
developmental tasks.
Accept changes in:
C Employment.
C Relationship with spouse.
C Relationship with children who are
becoming adults.
C Relationship with aging parents.
C Physical abilities.
Reevaluate one’s goals and accomplishments.
Maintain a satisfactory occupation.
Ego Integrity vs. Despair and
Disgust (acceptance of one’s own
life cycle)
Inability to find meaning in
life and accept life’s
limitations.
Events such as retirement,
loss of health or income,
death of spouse or close
friends, and isolation can
be devastating.
Look to the past without regrets.
Look forward to the future.
Develop leisure time activities.
Accept and adjust to physical changes of the
later years.
Relate to one’s spouse as a person rather than
a role.
Tell stories about their past.
Respond to and assist aging parents.
Toddler
3-6 years
Preschooler
6-12 years
School Age
12-19 years
Young
Adulthood
40-65 years
Middle-Aged
Adulthood
> 65 years
Older Adults
Or
60-74 years
Young-Old
75-84 years
Middle-Old
> 85 years
Old-Old
Begin to manipulate objects and the
environment.
Learn how to pull-to-stand, cruise, and often
walk.
Source adapted from:
EV:sec/4-16-13/Fall Pck Dev Tasks HO NUR 1010/Nsg/
1. Erikson, Erik, Childhood and Society. (New York: W.W. Norton and Company, 1963).
2. Sutterley and Donnelly, Perspectives in Human Development: Nursing Throughout the Life Cycle. (Philadelphia: Lippincott, 1975).
3. Bernard, Harold, Human Development in Western Culture. (Boston: Allyn and Bacon, Inc., 1978).
4. Taylor, Lillis, LeMone, Lynn, Fundamentals of Nursing. (Philadelphia: Wolters, Kluwer Health/Lippincott Williams and Wilkins, 2011).
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