Upload
terry-woods
View
219
Download
0
Embed Size (px)
Citation preview
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
1/17
Del Mar College Student: _________________________________________Nurse Education Dept. Week # ____________ Date: _________________________________
Level 1 Nursing - Adult Assessment FormPhase I: Preinteraction
Patient Initials: ____ Date of Admission: ________ DOB: ________ Age & Gender____ /____ Ht. & Wt. ____/__Religion: ______________ Culture/Ethnicity: _______________ Occupation: _____________________________Level of Education: ___________________ Primary Language: _______________ Code Status: ______________
Chief Complaint: ______________________________________________________________________________Primary Medical Diagnosis: _____________________________________________________________________Secondary Medical Diagnosis: ___________________________________________________________________Current Treatments: ___________________________________________________________________________Past Medical History (pre-existing): ___________________________________________________________________________________________________________________________________________________________Surgeries Present: _____________________________________________________________________________Surgeries Past: ____________________________________________________________________________________________________________________________________________________________________________Allergies: _________________________ Exercise: _____________________ ADLs: _______________________
Home Medications: ____________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________OTC Meds/Herbal: ____________________________________________________________________________
Disabilities: ___________________________________________________________________________________________________________________________________
Phase II: Initial InterviewLOC Oriented to
Other: _________________________________________________________________
staying focused, forgetfulness, headaches, or history of head trauma? __________________________________
___________________________________________________________________________________________ces Describe: ________________________________________________________________
Impairment Describe: ____________________________________________________________
es Type: ___________________________________________________________________________
Do you have numbness, tingling, or muscle weakness? Describe: ____________________________________________________________________________________________________________________
Describe ________________________________________________________1. Visual Impairment:2. Hearing Impairment:
___________
- -term Impaired-
Describe: __________________________________________
Variances:__________________________________________________________________________________
Day 1: Time________ B/P________ T________ Apical ________ R________ P________ O2________
Day 2: Time________ B/P________ T________ Apical ________ R________ P________ O2________Variances:
Vitals Signs
Throughout your assessment, rate pain on a scale of 0-10, with 0 being no pain, and 10 being the worst pain
imaginable. Describe quality, location, and frequency. Describe subjective and objective data as appropriate.*
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
2/17
Circulation
Oxygenation
Musculoskeletal
Phase III: Focused Interview
Heart Sounds: 1 2
-pitting Edema Scale: _________
Site Rate Rhythm* Quality Site Rate Rhythm* Quality Quality Scale:0 Absent
1+ Thready/Weak
2+ Normal
3+ Increased4+ Bounding
R = Regular
I = Irregular
Radial Posterior
Tibial
Brachial Pedal
Apical Others
_____________
__________________________________________________________________________________________
Variances:_________________________________________________________________________________
Rate: _____per min Quality: Depth:___________________________
-productive
Describe: ________________________________
Delivery Device
2 _______________Variances: _________________________________________________________________________________
_______
6. Activities of Daily Living: (Fill in the blanks with I = Independent A =Assist D = Dependent)
____Feeding _____Bathing _____Grooming ____Toileting ____Dressing
Muscle Strength: Strong Weak None Muscle mass/tone: _______________________________
Upper Extremity Grips: _____ Right _____ Left Lower Extremity Pushes:_____ Right _____ Left
ROMBalance Problems
Variances: _______________________________________________________________________________
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
3/17
General Health
GU - Genitourinary & Elimination
GI Gastrointestinal & Elimination
Describe: _______________________________________________________
4________
5. Have you had head or neck pain, neck masses, or swollen nodes: ____________________________________Lymph Node __________________
Variances: ____________________________________________________________________________________________________________________________________________________________________________
Description per: ____Nurse _____Patient________________________
2. Describe: _______________________________________________________
4.
____________________
6. Last 24 hr. fluid intake__________ ml 7. Last 24 hr. urinaryoutput __________mlBladder:
________________________
Sexual-Reproductive Pattern8 Males: Females:
Variances: _________________________________________________________________________________
__________________________________________________________________________________________
Description of bowel movement per _____Nurse _____PatientFood Allergies: ____________________
2. Nutritional Supplements: Type & Frequency ____________________________________________________
Fingerstick Frequency: ________________________
6. IBW: _______________ BMI: ______________7. Recent changes in Ap
Describe: ________________________________________________________________________________8. Recent Weight los ________ over how long ________________________
9
Date of Last BM:_____________ Patient regular bowel pattern___________________
Bowels:______
Medications/practices that affect bowel elimination: ________________________________________________
Variances: ____________________________________________________________________________________________________________________________________________________________________________
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
4/17
Nutritional-Metabolic: SKIN
Psychosocial
1. Color: Temperature 2. Turgor: Moisture 3.Assess:
Location: _______________________ Sizein cm: _________Edges -Approximated
Location: _______________________ Sizein cm: _________Edges -Approximated
strips
_________________________________________________________________________________________
8. Braden Score___________ Treatment/measures to be implemented: ________________________________
_________________________________________________________________________________________
9. Do you have frequent skin infections/explain? ___________________________________________________Variances: _________________________________________________________________________________
__________________________________________________________________________________________
Coping/Stress PatternWhat people give you the most support? _________________________________________________________
How do you deal with stress & resolve problems? _________________________________________________
Role/Relationship PatternDo you have regular social interaction? ________________________________________________________Can you identify your roles and relationships? ____________________________________________________
Value/Belief Pattern
What activities give you strength, comfort, support? ______________________________________________What influences your perception of health? _____________________________________________________
What activities help you maintain or improve your health? __________________________________________
What do you know about your current medical condition? __________________________________________Do you use any religious practices to help you cope? ______________________________________________
Self-Perception/Self-Concept PatternHow do you see yourself? ____________________________________________________________________
Sleep/Rest Pattern1. How many hours of sleep do you need to feel rested? __________ Current hours of sleep: __________2. How do you promote sleep or get back to sleep? ____________________________________________3. Do you take medications that promote sleep? ______________________________________________4. Do you have a bedtime routine? ________________________________________________________
Activity/Exercise? _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
5/17
Erik Ericksons 8 Stages of Psychosocial DevelopmentCheck behaviors observed on both positive and negative indicator columns. Evaluate behaviors in relation to the clients situation, age
and illness. Determine the clients strengths and areas that need support from evaluation of behaviors seen during contact with the
client. Make an assessment with rationale statement that identifies the level of development your client is functioning in.
Statement of client level of functioning assessment with rationale: _________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
STAGE AGE TASKCLIENT BEHAVIOR
Positive Indicators
CLIENT BEHAVIOR
Negative Indicators
INFANCYBirth- 18
monthsTrust vs Mistrust
HOPE/CONFIDENCE
Trusts others
Positive in Beliefs
Mistrusts
Withdraws
Estranged
EARLY
CHILDHOOD18 m- 3 years
Autonomy vs
Doubt & shame
WILL
Capable of free choice
Self control
Positive self-image
Compulsive self-restraint or
compliance
LATE CHILDHOOD 3-5 years Initiative vs Guilt
PURPOSE/COURAGE
Believes that can influence
environment
Lacks self confidence
SCHOOL AGE 6-12 years Industry vsInferiority
COMPETENTDexterous ability to:
Create
Develop
Manipulate
Loss of hopeSense of well-being only
mediocre
ADOLESCENCE 12-20 yearsIdentity vs
Role Confusion
FIDELITY
Can sustain loyalty in difference
in values
Demonstrates coherent sense of
self
Confusion
Indecisiveness
Unable to find occupational
identity
YOUNG ADULT 18-25 years Intimacy vsIsolation
LOVE
Mutual intimate relationship
with another
Commitment to work
relationships
Impersonal with relationship
ADULTHOOD 25-65 yearsGenerativity vs
Stagnation
CAREWidened concerns for what life has
generated through:
Creativity
Production
Love
Self-indulgent
Self-Concern
Lack of interest or
commitments
MATURITY65 years
to death
Integrity vs
Despair
WISDOMAbility to see life as successfully
achieved:
Detached concern with life:
Accepts worth of own life
Accepts possibility of own death
Sense of loss
Contempt for others
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
6/17
Clinical Prep / Patho
Medical Diagnosis: _____________________________________________
Textbook Disease Process My Patient Findings
Signs/Symptoms per Textbook
Textbook Expected Medications Ordered for this Condition
Textbook Expected Diagnostics Ordered for this Condition
Textbook Nursing Interventions for This Conditions
Patient Signs/Symptoms with this Condition
My Patient Medications Ordered specific for this Condition
My Patient Diagnostics Ordered specific for this Condition
--Interventions Specific for this Condition should be similar if
not the same,
My PRIMARY Nursing NANDA for this condition:
Problem
RT
AEB
Does your patients care as the Dr. has ordered compare or come close to Text Book plan? Yes or No, explain:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
7/17
Diagnostic Tests / LAB
1. Chemistry (BMP): Is this test done Daily? Yes No
2. Hematology: Is this test done Daily? Yes No
3. Urinalysis:
4. Liver Function
Test Component Normal
Values
Admission
Results
Recent
Results
Indications/Disease/Conditions
Na+
K+
Cl-
CO2
BUN
Creatinine
GFR
Glucose
Ca
Test Component
Auto / Manual
Normal
Value
Admission
Results
Recent
Results
Indications/Disease/Conditions
WBC
RBC
Hgb
HctMCV
RDW
Platelets
Is there a Manual Difference? Yes No (circle one) Which components?
Test Component Normal
Value
Admission
Results
Recent
Results
Indications/Disease/Conditions
Appearance
Color
Spec. Gravity
Bacteria
Protein
WBC
RBC
Glucose
Test Component Normal
Value
Admission
Results
Recent
Results
Indication/Diseases/Conditions
Albumin
PrealbuminBilirubin, total
Bilirubin, directBilirubin, indirect
AST / SGOT
ALT / SGPT
Protein, total
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
8/17
Diagnostic Tests / LAB
5. Coagulation Studies Is this test done Daily? Yes No
6. Arterial Blood Gases (ABGs) Is this test done Daily? Yes No
7. Cardiac Enzymes
8. Any Other Lab Study
9. Radiology
10. Finger Stick(s) Glucose (FSBS) Checks are they ordered: Yes No
Test Component Normal
Value
Admission
Results
Recent
Results
Indications/Diseases/Conditions
Platelets
PT
INR
PTT
Does this patient take Coumadin, Heparin, or Lovenox? Yes No (circle one) Which?
Test Component Normal
Value
Admission
Results
Recent
Results
Indications/Diseases/Conditions
PH
PCO2
PO2
HCO3
O2 sat
Test Component NormalValue
AdmissionResults
RecentValues
Indications/Diseases/Conditions
AST/SGOT
CPK
CPK-MB
LDH
Myoglobin
Troponin I
Troponin T
CRP
Test Component Normal
Values
Admission
Results
Recent
Results
Indications/Disease/Conditions
Date Exam Results Reason Ordered
Normal Range:Drs Order
Clinical Day 1 0700 1130 1630 2100 OtherCoverage given
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
9/17
Medication & Research Sheet / MAR
Lab IndicationsWhat lab values does the medication INC. or DEC.?
Medication Drug +
dosage, route, & frequency
Functional
ClassificationAction
Why is your client on
this drug?
Lab Indications
(Cite data that the drug is
therapeutic for your client)
Nursing Implications
(Monitor, Assess, when to Hold)
CARE PLAN #1 NANDASMART = Specific, Measurable, Attainable, Realistic and Timed ACT = Assess, Care, Teach
Data Collection Nursing Diagnosis
(3 part NANDA)
Interventions & Provide
Rationales for each intervention
Evaluation of Patient Response to
Nursing Interventions
SUBJECTIVE
DATA
P = GOAL Statement Was Your Overall Goal Met?YES or NO
Explain:
Et. = OUTCOME #1 A =
C =
T =
Did pt. achieve Outcome #1?YES or NO
Explain:
OBJECTIVE DATA
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
10/17
S /S = OUTCOME #2 A =
C =
T =
Did pt. achieve Outcome #2?YES or NO
Explain:
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
11/17
Care Plan #1: EVALUATION & MODIFICATIO
Evaluation ofInterventions /
Outcomes
New Data:For changes to Nrs Dx or
reasons to keep the current
Nrs Dx
Modifications: New Nrs DxChange to another problem
based on new data or if keeping
current Dx
New Goals / Outcomes Interventions: Revised / New
OC #1 SUBJECTIVE DATA P =
E = OC #1 A =
C =
T =OC #2 OBJECTIVE DATA
Outcomes - Circle One:
Met
Not Met
Partially Met
S /S = OC #2 A =
C =
T =
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
12/17
CARE PLAN #2 NANDASMART = Specific, Measurable, Attainable, Realistic and Timed ACT = Assess, Care, Teach
Data Collection Nursing Diagnosis
(3 part NANDA)
Interventions & Provide
Rationales for each intervention
Evaluation of Patient Response to
Nursing Interventions
SUBJECTIVE
DATA
P = GOAL Statement Was Your Overall Goal Met?YES or NO
Explain:
Et. = OUTCOME #1 A =
C =
T =
Did pt. achieve Outcome #1?YES or NO
Explain:
OBJECTIVE DATA
S /S = OUTCOME #2 A =
C =
T =
Did pt. achieve Outcome #2?YES or NO
Explain:
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
13/17
Care Plan #2: EVALUATION & MODIFICATIO
Evaluation ofInterventions /
Outcomes
New Data:For any changes to Nrs Dx or
reasons to keep the current
Nrs Dx
Modifications: New Nrs DxChange to another problem
based on new data or if keeping
current Dx
New Goals / Outcomes Interventions: Revised / New
OC #1 SUBJECTIVE DATA P =
E = OC #1 A =
C =
T =OC #2 OBJECTIVE DATA
Outcomes - Circle One:
Met
Not Met
Partially Met
S /S = OC #2 A =
C =
T =
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
14/17
APIE Chart
A = Assessment - You should have an initial assessment on your patient and an assessment per hospiprotocol every 2-8 hours. As changes occur, you may add problems to your list or delete them from theproblem list.P= Problem + Etiology + Signs and Symptoms (Nursing diagnosis that gives documentation of initialassessment of the client in relation to an identified problem. Each problem must be numbered and openonly one time. Interventions and Evaluations (I and E) that follow must have that same problem number
I = Intervention - Document nursing orders or what nurse does for client.E = Evaluation - Document client response to interventions. Includes reevaluation of signs/symptomslisted in the problem section.
DATE:_________________________________
PhysicalProblem #
NANDA 3 part statement
PsychosocialProblem #
NANDA 3 part statement
Time APIE Progress Note
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
15/17
**Continue on additional paper as needed.
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
16/17
Del Mar CollegeWeekly Self Evaluation
Write a self-evaluation each clinical week. Give specific examples of how each of the criteria was met.
Caringestablish trusting, interpersonal relationships with adult clients, incorporating caring behaviors. Include thefollowing:How did you develop rapport and awareness of cultural respect, demonstrate an understanding of the advocacy process,and develop patience and compassion?
Communicationutilize basic communication skills when caring for adult clients. Include the following:How did you apply general principles of therapeutic communication, utilize professional and personal qualities to enhancecommunication, document in written and electronic records?
Competencyprovide safe, evidence-based nursing care to adult clients. Include the following:How did you implement safe fundamental nursing care for adult clients, recognize responsibility for quality of nursing careand identify the value of life-long learning and recognize the need for self-assessment to improve your own nursingpractice?
Clinical Decision-Making begin using critical thinking skills and nursing process while providing basic nursing care toadult clients. Include the following:How did you distinguish normal vs. abnormal function and factors that inhibit normal function, demonstrate technologicalskills and focused nursing assessment skills, and administer medications using the five rights?
Comments:
7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet
17/17
Student Name________________________
Date_______________________________
Careplan Grading Rubric
Areas Evaluated Points
Possible
Points
Possible
Points
Earned
Comments
ASSESSMENT Week 1-4 Week5-9
1. Adult Assessment 15 102. Pathology Sheet 5 5
3. Medications 15 10
4. Labs/Diagnostics 15 10
NURSING CAREPLAN
1. Diagnosis 15 10
2. Goal 10 10
3. Outcomes 10 10
4. NursingInterventions with
Rationales
10 10
5. Evaluations 0 10
6. Modifications 0 10
DOCUMENTATION
1. Correct charting
format (APIE, AIR,DAR) Correct use ofmedical terms,
spelling, grammar,
punctuation
5 5
TOTAL 100