please fill out all forms
REPORT DATA (Information obtained from RN, morning report, clarification of information obtained from clinical instructor)
· Date of Care Date of Admission
· Client Initials Allergies
· Age: Gender Marital Status
· Reason for admission (chief complaint)
· Past Medical History/Operation/Procedure (include date)
· Advance Directives
· Living Will_ _ YES NO
· Power of attorney YES NO
· Do Not Resuscitate (DNR) YES NO
· Activity orders
· Vital signs(frequency)
· Intravenous Fluids/Saline Lock
· Diet/Intake & Output
· Telemetry
· Oxygen
· Drains/Wounds
· Procedures/specimens/medications
· Isolation
· Scheduled Therapies/Other
· Special Equipment
FOCUSED ASSESSMENT:
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If abnormal findings are assessed in ABC. STOP! CORRECT! Then continue to assess and reassess. (What must be recognized as clinically significant?) |
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· AIRWAY(Patency)
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· APPEARANCE/COGNITIVE (LOC, Posture and position, Attention Span)
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· BREATHING (Effort: unlabored or labored, Respiratory Rate and Rhythm, Lung sounds, Oxygen therapy, Oxygen saturation)
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· BEHAVIOR (Facial expressions, Speech, Sensory deficits, Mood)
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· CIRCULATION (Apical pulse: regular, irregular, Blood Pressure, Peripheral pulses, Capillary refill, Skin color and moisture, Temperature, Edema)
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· PAIN (location, severity, duration, onset, frequency, relief measures effectiveness of relief measures )
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· ENVIRONMENTAL SAFETY (Activity/Risk for fall or injury)
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· IN: What is going in? (Intravenous Solutions, Enteral)
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· OUT: What is coming out? (tubes, drains, drainage [amount and color])
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· PRIORITY ASSESSMENT (Top priorities regarding your assigned client)
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Remember to mark off checkbox if any of these assessments were also a part of your focused assessment. |
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· SKIN INTEGRITY (Braden Scale rating (report data), Actual or potential wounds , turgor) |
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· GASTROINTESTINAL (weight, height, BMI, hydration, diet, appetite, abdomen, stool) |
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· GENITOURINARY (catheter, dialysis, urine characteristics) |
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· REPRODUCTIVE (Gravida, Para, AB, LC, menarche, menopause, STI ) |
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· MUSCULOSKELETAL (gait, posture, devices, ROM, strength) |
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· NEUROLOGICAL (PERRLA, EOM’s, seizures, Glasgow Coma Scale) |
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· PSYCHOLOGICAL (communication, emotions, stressors, concerns, anxiety, coping mechanisms) |
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· SOCIOCULTURAL (living arrangements, occupation, support systems, education, cultural beliefs, use of alternative therapies) |
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· DEVELOPMENTAL (Erikson’s Life Stage, developmental level, any delay or at risk for delay or regression) |
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· SPIRITUAL (religious affiliation or belief system, activities) |
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· DISCHARGE PLANNING/HEALTH PROMOTION (self-care needs, educational needs and barriers, resources, equipment/environmental needs, plan upon discharge) |
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CLIENT ASSESSMENT
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Medications: · Classification · Generic Name · Trade Name · Dosage · Route |
Reason the Client is Receiving |
Nursing considerations |
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Therapeutic effect |
Assessments and Lab Test Considerations prior to administration |
Interactions: Drug-Drug; Drug-Food |
Major Side Effects |
Client/Family teaching
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Diagnostic and/or Laboratory Test |
Normal Values |
Client’s Results |
Reason this being monitored for this client. |
What is the clinical significance to the nurse caring for this client? |
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Admission |
Current |
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HEMATOLOGY WBC (NUR 112) |
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RBC (NUR 112)
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HGB (NUR 112)
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HCT (NUR 112)
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PLATELET (NUR 112)
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aPTT/PTT (NUR 112)
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PT (NUR 112)
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INR (NUR 112)
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SED RATE
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Bleeding time |
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BLOOD CHEMISTRY POTASSIUM (NUR 112)
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SODIUM (NUR 112)
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MAGNESIUM (NUR 112)
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CALCIUM
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PHOSPHORUS
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BUN (NUR 112)
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CREATININE (NUR 112)
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Diagnostic and/or Laboratory Test |
Normal Values |
Client’s Results |
Reason this being monitored for this client. |
What is the clinical significance to the nurse caring for this client? |
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Admission |
Current |
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GLUCOSE (NUR 112)
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HgbA1C
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ALBUMIN (NUR 112)
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SERUM LIPIDS CHOLESTEROL |
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TRIGLYCERIDES
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LDL’S
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HDL’S
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LIVER ENZYMES ALT |
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AST
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Ammonia
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Bilirubin
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CARDIAC
TROPONIN |
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MYOGLOBIN
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CK-MB
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BNP
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Blood Serum Levels (i.e. Digoxin and Lithium) ________________
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Diagnostic and/or Laboratory Test |
Normal Values |
Client’s Results |
Reason this being monitored for this client. |
What is the clinical significance to the nurse caring for this client? |
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Admission |
Current |
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BLOOD GASES pH |
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PCO2
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PO2
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HCO3
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URINALYSIS Color |
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Glucose |
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Ketone |
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pH |
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Protein |
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Urobilinogen |
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RBC |
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WBC |
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Nitrates |
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Specific Gravity |
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OTHERS CHEST X-RAY
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EKG
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