Download Normal Assessment Data

Assessment and Nursing Care Plan
Student: _____________________ Signs and Symptoms on Admit:
Admit DX_____________________________________________________
Allergies:
Date & name of Surgery/procedure/heart catheterization:____________________________________Date of Admit:
Age:
Medical/Surgical History:_________________________________________________________________________________________________
Data Clustering
Normal Assessment Data
Cognitive/Perceptual
□ Awake & Alert
□ Orient x 3
□ Pupils PERRLA Bil
□ Cooperative
□ Verbally responsive
□ Speech clear
□ Sensation intact
□ Short-term memory intact
□ Long-term memory intact
□ Glasgow Coma Scale ____
□ Other:
Normal Assessment Data
Comfort/Sleep/Rest
□ Pain Scale __________
□ Restful Sleep
Normal Assessment Data
Activity/Exercise
Respiratory
□ Resp even and unlabored
□ Breath sounds clear bil
□ Resps 8 _____ 12 _____
Nursing Diagnosis/Goals &
Outcomes
NS Dx: Diagnosis , Related To
(etiology), Secondary to (Dx)
G & O: Patient will___,
within___, as evidenced by___
Nursing Actions
What you will assess.
What you will teach.
What you will implement.
What labs you will review.
What medications you will give.
Abnormal Assessment Data
Include: Invasive Devices,
Medications Administered, Labs,
Diagnostic Tests
Relevant Health
History Gathered and
Home Medications
Abnormal Data
Relevant History
How much sleep does pt
get at home (describe)?
NS Dx/Goals
Nursing Actions
Relevant History
What are normal
activities at home (be
very specific)?
 Smoker
NS Dx/Goals
Nursing Actions
Abnormal Data
Data Clustering
Ranges ______________
□ O2 Sat 8 ____ 12 _____
□ Oxygen device _________
Normal Assessment Data
Circulatory
□ HS S1 & S2 audible
□ Regular rhythm
Radial pulses
□ 2+/3 bil
□ Pulse 8 ______ 12 ________
□ Range __________________
Pedal/Tibia pulses
□ 2+/3 bil
□ Capillary refill <3 sec x 4 ext
□ No obvious venous patterns
□ Hair evenly distributed
□ BP 8 _______ 12 ________
Range S _______ D_______
Abnormal Data
Musculoskeletal
□ Activity Level ____________
□ Independent ADLs
□ Steady gait
□ Full Active ROM x 4 ext
□ Coordinated movements
□ Muscle tone firm x 4 ext
□ Muscle strength 5/5 x 4 ext
□ Alignment symmetrical
Normal Assessment Data
Abnormal Data
Nutritional-Metabolic
Glucose checks: __________
□ Diet _______________
□ Complaint
Insulin: _________________
□ Breakfast _______%
□ Lunch _________ %
□ Range ____________%
□ Weight ___________
□ BMI ___________
Fluid and Electrolytes
 Oxygen at Home
Relevant History
Relevant History
Wt. loss/gain _________
Time for wt loss/gain
____________________
What are pts
likes/dislikes?
What does pt usually eat
at home?
Nursing Diagnosis/Goals &
Outcomes
Nursing Actions
NS Dx/Goals
Nursing Actions
NS Dx/Goals
Nursing Actions
Data Clustering
□ Mucus membranes intact
□ Skin turgor < 3 secs
□ Intake ______ Range:_____
□ Output ______ Range: _____
Nursing Diagnosis/Goals &
Outcomes
Nursing Actions
NS Dx/Goals
Nursing Actions
NS Dx/Goals
Nursing Actions
What does pt usually
drink at home?
How much does pt drink
daily at home?
Abdominal Assessment
□ Non-distended
□ Bowel sounds ____________
□ Soft, non-tender
Normal Assessment Data
Elimination/Sexuality
Bladder
□ Bladder non-distended
□ Meatus intact
□ Urine clear yellow
□ No urinary assistive devices
Bowel
□ Brown formed stools
□ Last bm _________
Abnormal Data
What is pt bowel habits
at home? Is there any
type of incontinence
(explain)?
Sexuality
□ Breasts no lesions/discharge
□ Genitals no lesions/discharge
□ No Concerns
Normal Assessment Data
Integument
□ Temp 8 ______ 12 _______
Range _________________
□ Skin warm, dry
□ Color evenly distributed
□ No cyanosis
□ Braden Scale __________
Lines/Drains/Wounds
□ IV devices
□ NG tubes
□ Drainage tubes
Relevant History
What are pts urinary
habits at home? Is there
any type of incontinence
(explain)?
Abnormal Data
Relevant History
NS Dx/Goals
Nursing Actions
Nursing Diagnosis/Goals &
Outcomes
Data Clustering
Nursing Actions
□ Wounds
□ Surgical incisions
Psychosocial Data
Role/Relationships
Erickson’s Dev Level:
NS Dx/Goals
Nursing Actions
NS Dx/Goals
Nursing Actions
NS Dx/Goals
Nursing Actions
Meeting Tasks:
Lives with:
Support system:
Wage earner:
Self-Perception
Perception of Why Hospitalized:
Awareness of Health Status:
(Health Behaviors/Risk Factors):
Other:
Value-Belief
Things that are important:
Impact of illness on religious beliefs/practices
Chaplain Visits:
Religion:
Braden Scale
0-12=strict pressure ulcer prevention precautions
13-18=Moderate pressure ulcer prevention precautions
19-23=Pressure ulcer prevention precautions
Sensory perception: Response to pressure related discomfort
Completely limited (unresponsive, quad, coma)
Very limited (responds painful stimuli, paraplegic, semicoma)
Slightly limited (responds some sensory impairment, CVA)
No impairment (no limiting sensory deficit)
Moisture degree: Skin exposed to moisture
Constant moisture (incontinent, 2 or more linen changes/8 hr)
Moist (often incontinent, 1 linen change/8 hr)
Occasionally moist (seldom incontinent, 2 linen changes/24hr)
Rarely moist (skin is dry, routine linen change)
Activity: Degree of physical activity
Bed Rest (confined to bed)
Chairfast (minimum weight bearing, ambulatory c assist)
Walks occasionally (ambulatory short distance, sits
mostly)
Walks frequently (ambulatory outside room, BID)
Today’s score __________
1
2
3
4
1
2
3
4
1
2
3
4
Mobility: Ability to control, change body position
Completely immobile (cannot move self)
Very limited (makes insignificant movements)
Slightly limited (makes slight changes independently)
No limitations (makes major, independent changes)
Nutrition: Usual food intake pattern
Very poor (NPO, IV > 5 days, less than 1/3 meals)
Probably inadequate (needs assistance, less than 1/2
meals)
Adequate (TPN, enteral needs met, greater than 1/2
meals)
Excellent (no supplement, eats most meals)
Friction and shear: Ability to maintain body position
Problem (requires complete assist, slides down in bed/chair)
Potential problem (requires max assist, sometimes slides down
No apparent problem (independent, maintains positions)
8
Intake
Output
Meals
Weight
Bowel Mov’t
7A-7P
12
4
8
Temp
Pulse
Resp
BP
Parenteral
Oral
Blood/Plasma
Piggy back
Tube feeding
GU irrigant
12Hr Total
24 Hr Total
Catheter
Emesis
Suction
Voiding
Drain
12 Hr Shift
24 Hr Shift
B ___%
L ___%
1
2
3
4
1
2
3
Graphic and I & O Record
Date
Hour
1
2
3
4
D ___%
7P-7A
12
4
Clinical Reflections
Directions: Clinical reflections must be completed each week and submitted with the required
paperwork as directed. Please be give specific examples from the clinical day when answering the
following questions.
Discuss your strengths in clinical this week.
Discuss aspects of clinical that you would like to improve on next week? Explain why you see the
need for improvement and how you will go about making the change. Give a specific example of
something that happened that you could have responded or reacted differently that would have
improved the outcome.
Give a specific example of how you implemented or observed critical thinking during your clinical
experience? (Ex: decisions re med administration, interpretation of assessment data)
Give a specific example of a safety concern that you identified during the clinical day?
Extras I did today: