Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet

7/31/2019 Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet

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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.*


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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: _______________________________________________________________________________


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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: ____________________________________________________________________________________________________________________________________________________________________________


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? _________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


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


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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:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


7/17

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


WBC

RBC

Hgb

HctMCV

RDW

Platelets

Is there a Manual Difference? Yes No (circle one) Which components?


Value

Admission

Results

Recent

Results


Appearance

Color

Spec. Gravity

Bacteria

Protein

WBC

RBC

Glucose


Value

Admission

Results

Recent

Results

Indication/Diseases/Conditions

Albumin

PrealbuminBilirubin, total

Bilirubin, directBilirubin, indirect

AST / SGOT

ALT / SGPT

Protein, total


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


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?


Value

Admission

Results

Recent

Results


PH

PCO2

PO2

HCO3

O2 sat

Test Component NormalValue

AdmissionResults

RecentValues


AST/SGOT

CPK

CPK-MB

LDH

Myoglobin

Troponin I

Troponin T

CRP


Values

Admission

Results

Recent

Results


Date Exam Results Reason Ordered

Normal Range:Drs Order

Clinical Day 1 0700 1130 1630 2100 OtherCoverage given


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


10/17

S /S = OUTCOME #2 A =

C =

T =


Explain:


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 =


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 =


Explain:

OBJECTIVE DATA

S /S = OUTCOME #2 A =

C =

T =


Explain:


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 =


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


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**Continue on additional paper as needed.


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:


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

Revised Level 1 Nursing - Assessment Form-1.Docxmed Sheet

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