Community College in Orange County, NY | SUNY Orange



DATE:Click here to enter a date. _ Pt. Initials: ____________ ROOM# _______________Student:_____________________________ ALLERGIES Click here to enter text.Circle or check your assessment data. When you see ** you need to document in a narrative note for the client’s chart further details of the assessment or problem identified, the treatment and the client’s response to that treatment.Physiologic needs (MASLOW):Glasgow Coma Scale (GCS)Oxygenation: Neurological assessmentEye Opening ResponseSpontaneous--open with blinking at baseline4 points ?Opens to verbal command, speech, or shout3 points ?Opens to pain, not applied to face2 points ?None1 point ?Verbal ResponseOriented5 points ?Confused conversation, but able to answer questions4 points ?Inappropriate responses, words discernible3?points ?Incomprehensible speech2 points ?None1?point ?Motor ResponseUsually record best arm responseObeys commands for movement6?points ?Purposeful movement to painful stimulus5 points ?Withdraws from pain4 points ?Abnormal (spastic) flexion, decorticate posture3 points ?Extensor (rigid) response, decerebrate posture2 points ?None1 point ?-95250124460Pupil ReactionB-brisk ? Equal ? Unequal ?S-Sluggish ? NR - no reaction ?C-eye closed by swelling ?Pupil size(mm)Right Click here to enter text.Left Click here to enter text.Mentation4-Alert ? 3-lethargic ? 2-Stuporous ? 1-Comatose ? Emotional stateCA-Calm ?AN-Anxious ?CO-Combative ?AG-agitated ? GCS Total Click here to enter text.2) Oxygenation: Cardiovascular AssessmentTemp site – record with temp measurementO-oralR-rectalA-axillaryT-TympanicBP SITE – record where takenRUA-right upper arm LUA –left upper armRLA-right lower armLLA-left lower armRLL-right lower legLLL-left lower legPULSE SITE – record where taken R-Radial B-Brachial F-femoralA-Apical O-other (location)SKIN COLORN-Normal for ethnicityF-FlushedP-PaleC-CyanoticM-MottledJ-JaundiceSKIN TEMPH-HotW-warmC-CoolO-ColdSKIN PALPATIOND-DryM-MoistC-Clammy/DiaphoreticTIMETempBP/SitePulse rate/siteSkin colorSkin TempSkin palpationPULSE SITES – record which pulse sites assessed for pulse strength on each extremityUpper : R-radial U-ulnar B-brachialLower: F-femoral P-popliteal DP-dorsalis pedis PT-posterior tibial PULSE STRENGTH3+Bounding2+Normal1+ WeakD-DopplerA-Absent EDEMA0-None LocationTR-Trace H-Hand1+ 3+ A-Arm2+ 4+ F-FootG-Generalized A-AnkleW-** Skin Weeping T-Thigh**Requires further documentationCAPILLARY REFILLB- Brisk (< 3 sec)M- Moderate (>3 sec, <5 sec)S – Sluggish (>5 sec)Right upperLeft upperRight lowerLeft lower3) Oxygenation: Respiratory AssessmentAIRWAY CODETR-TracheostomyL-LaryngectomyN-No Artificial Airway OXYGEN THERAPY:NV-Non-Invasive ventilatorTC-Trach CollarNC-Nasal CannulaVM-Venti-MaskNRB-Non-Rebreather MaskRA-Room AirO-Other( requires comment)SECRETIONS:S-Small W-WhiteM-Moderate Y-YellowC-Copious G-GreenTN-Thin T-TanTK-Thick F-Foul BT-Blood-Tinged N-NoneBreath Sounds**CL-ClearCR CracklesW-WheezeR-RhonchiD-Diminished** Note required to describe breath sounds if other than clearINTERVENTION CPT-Chest PhysiotherapyIS-Incentive SpirometryS-SuctionTIMERRAir-wayO2 therapyO2 FlowPulse OxCoughSecretionsBreath SoundsInterventionHx. of SMOKINGNo YesNo YesNo YesPacks per day Click here to enter text.4) Oxygenation: Fluid and Electrolytes AssessmentSkin Turgor: MUCOUS MEMBRANESN-Normal TD-Tongue Dry P-Poor LD- Lips Dry/Cracked TM – Tongue Moist LM - Lips MoistFluid IntakeThirst-Presence of thirst Yes ?No ?Nausea/ Vomiting**Yes ?No ?NPO Yes ?No ?Fluid Intake previous 24 hrs. Click here to enter text.**Requires noteFluid Restriction Previous 24 hrs.Yes ? No ?Fluid Restriction amt. for 24 hrs. and distribution every shift. Total mL Click here to enter text.Day shift Click here to enter text. Night shift Click here to enter text.IV InfusionYes ? No ?Site FlushYes ? No ?IV D/C **Yes ? No ?** Note neededTime Skin TurgorMucous MembranesFluid Intake for shiftFluid allowed for shiftIV site location/ Condition/Pain** Note neededIV Solution and rate5) Physiologic needs: Nutrition AssessmentOrdered NutritionR-Regular T-TPN/PPNS-soft P-PureedCL-Clear liquidNPO-Nothing by mouthE-Enteral feeding (type)O-other (specify)DenturesU-UpperL- LowerB- BothO-OwnN-Nonep-PartialProblemsE-EatingS-SwallowingH-HeartburnT-TasteC-chewingN-NoneChange in WeightYes** ?No ?** Note neededDietary Supplement typeClick here to enter text.% of meal consumedOrdered nutritionDenturesProblemsWeightHeightDietary Supplement(Amount taken)6) Physiologic needs: Elimination Assessment6a. GI assessmentABDOMEN INSPECTION:F-FlatD-DistendedO-ObeseC-Concave Colostomy ? Yes** requires note ? No BOWEL SOUNDS3+ Hyperactive2+ Normal1+ Hypoactive0-AbsentPALPATIONS-SoftF-FirmR-RigidN-GuardingNT-Non-TenderT-TenderBowel movementSizeS-smallM-mediumL-largeDRAINAGE COLOR:G-GreenBR-BrownBL-BlackY-YellowR-RedCG-Coffee GroundN/A-Not applicableGI Tube typeSalem sump ?Feeding tube ?PEG ?J-Tube ?Placement confirmation method: Aspiration ?Air bolus ?X-ray ? Date Click here to enter text.TUBE SUCTION:LIS-Low Intermittent SuctionLCS-Low Continuous SuctionG-Gravity DrainageC-ClampedTimeInspectionBowelSoundsPalpationBM(Size, ColorConsistency)DrainageColorTube typeTube Location:(e.g., left nare, RUQ)Tube suctionResidual/ amount of drainage or vomit6b. GU assessment GU CATHETER: typeI-IndwellingS-StraightSP-SuprapubicN-NephrostomyN/A-not applicable URINE COLOR:Y-Yellow A-Amber N-Colorless B-Brown O-Orange R-RedP-Pale D-DarkCLARITY:C-ClearT-TurbidSEDIMENTP-Present0- NoneTOILETINGS-SelfA-BRP w/assistC-Bedside commodeI-Incontinent @ timesB-incontinence briefTIMECatheter typeDays in placeUrine ColorAmount voided/emptiedClaritySedimentToileting7) Physiologic needs: Mobility & ActivityROM: RANGE OF MOTION:A-ActiveP-PassiveStrength0-No movement1-Trace2-Movement but not against gravity3-Movement against gravity but NOT against resistance4-Movement against Gravity AND against some resistance5-Full powerAMBULATION:S-SelfA-AssistW-WalkerCR-CrutchesCA-CanePT-Physical therapyRVS-REDUCED VENOUS STASIS INTERVENTIONSS-Elastic Stockings onO-Elastic Stockings offA-Ace wrapsM-Sequential Compression Machine F-Foot Pump OnREPOSITIONING:R-Right SideL-Left SideS-SupineP-ProneO-OOB to chairBED POSITION:F-FlatL-Low Fowler’sSF-Semi-Fowler’sHF-High-Fowler’sT-TrendelenburgRT-Reverse TrendelenburgTIMEROMStrengthRU/LU/RL/LLAmbulationReduced Venous Stasis InterventionsRepositioning & timeBed Position8) Physiologic needs: Rest and Sleep (Check to mark response)Assessment of Sleep PatternDifficulty falling asleep?Difficulty staying asleep longer than 4 hrs.?Uses a prescription sleep aide nightly? Drug name: Uses an OTC sleep aide, nightly? Drug name:Denies sleep disturbance.?Sleep Aides/Methods tried with or without success. Click here to enter text.Client’s rest, sleep goal:Click here to enter text.9) Physiologic needs: PainDESCRIPTION of PREDOMINANT PAIN:P-Prickling SH-SharpA-Aching ST-StabbingB-Burning PR-PressureT-Throbbing O-OtherPain scale used:N-NumericF-FacesP- PAINADV-Verbal descriptorFREQUENCY of Pain: C-ConstantE-EpisodicWM with MovementWB with breathingWhat worked in the past?Click here to enter text. INTERVENTIONS: P-Pharmacological H-Heat R -Relaxation C-Position for comfort I-Imagery E-Emotional Support D-Distraction Q-Quiet Environment M-Massage O-OtherTIMELocationDescriptionIntensity (0-10) and scale usedFrequencyIntervention** Note required09277355772150-109220001000124-137795004448174-109220003314699-109220002181224-109220004286258127900169545071754002257425812790027432007175400331470071754003857625717540044481757175400515302571754005886450717540010572758127900 0 1 2 3 4 5 6 7 8 9 10 No Pain Mild Pain Moderate Pain Severe Pain Worse possible pain PAINAD scale (Pain Assessment in Advanced Dementia) Clinical Assignment Packet Nursing I Spring 2016Item123ScoreBreathing independent of vocalizationNormalOccasional labored breathing. Short period of hyperventilationNoisy labored breathing. Long period of hyperventilation. Cheynes-Stokes respirationsClick here to enter text.Negative vocalizationNoneOccasional moan or groan. Low level speech with a negative or disapproving qualityRepeated troubling calling out. Loud moaning or groaning. Crying.Click here to enter text.Facial expressionSmiling or inexpressiveSad, frightened, frownFacial grimacingClick here to enter text.Body languageRelaxedTense. Distressed pacing. FidgetingRigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.Click here to enter text.ConsolabilityNo need to consoleDistracted or reassured by voice or touchUnable to console, distract or reassureClick here to enter text.Safety and security needs (MASLOW)Total Click here to enter text.1) Skin and Safety AssessmentsSKIN CONDITION:I-IntactN-Non-Intact * *(Requires further documentation)WOUND TYPE:P-Pressure ulcer S-Surgical woundL-Laceration A-AbrasionE-Ecchymosis R-Rash SURGICAL DRAINSYes** ? ** Note neededNo ?DESCRIPTIONB-Blanching ErythemaStage I (Non-Blanching Erythema )Stage II: (Skin open to superficial layer)Stage III (Skin open to SC tissue layer)Stage IV (Skin open to muscle or bone)U-Unstageable – Eschar presentDTI-Deep tissue injuryBATHC-CompleteP-PartialS-SelfA-AssistSIDE RAILS:4-4 Rails Up3-3 Rails Up2-2 Rails Up1-1 Rail Up655319-3175000- Side Rails **BRADEN SCALE SCORE#_____ HIGH ?MED ?LOW ?**FALL RISK Score # _____HIGH ? MED ? LOW ?Fall risk scale used Click here to enter text.Wound type/Size (cm)/LocationSurgical drain type and locationDescription (wound and drainage)BathSiderailsClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Love and belonging needs: MASLOWPsychosocial AssessmentClient report of Family/Friends:Click here to enter text. Next of Kin (Ask)_Click here to enter text. Religious Affiliation_Click here to enter text. Indicators—Cards ? Flowers ? Family Photos? Additional Data/Concerns: Click here to enter text. Self-Esteem needs: MASLOWFamily Role_Click here to enter text.____ Grooming equipment at bedside: OccupationClick here to enter text._______ Brush/Comb? Toothbrush ? Toothpaste Other Toiletries:Click here to enter text.______ Interest in appearance_Click here to enter text._____Additional Data:Click here to enter text. Self-Actualization needs: MASLOWClient report of satisfaction with life: _Click here to enter text.___________________________________________________________________________________________________________________________________________________Independence: _Click here to enter text._____________________________________________Creativity: Click here to enter text._________________________________________________Additional Data: Click here to enter text.__________________________________ERICKSON’S STAGE OF DEVELOPMENT: (1) State the Developmental Stage the client is exhibiting. (2) Include what part of the stage best represents the client’s behavior and WHY you feel this is the part of the stage the client is exhibiting? (Make sure you explain your decision process in your explanation.) Click here to enter text.Nurses Note – Enter assessment details, problems, interventions and outcomes Date/time: NotesClick here to enter text.Click here to enter text. ................
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