Associate Degree Program in Nursing

Napa Valley College

Associate Degree Program in Nursing

NUR 143

Assessment & Plan Flowsheet

Describe assessments that are not within normal limits

Neuro/Sensory

LOC
Speech/Pupils
Motor Response
Communication
Vision/Hearing
Restraints
Pain /
Alert Oriented Disoriented Lethargic Unresponsive

Clear Slurred Aphasia Nonverbal PERRL Other (L) (R)

Follows instruction/spontaneous movement Other ______

Movement/Strength of U.E. Rt Lt L.E. Rt L ______

Grasps ideas and questions Other______

WNL Wears glasses Blind WNL Hearing aid R L Deaf
NA Type ______
None Yes Location:______Intensity (0-10)______Radiates______
Relieved by:______
Other observations:______
Plan: ______
______

Cardiovascular

Pulses
Heart sounds
Edema
Telemetry / R Radial R Pedal
Rhythm: Regular Irregular Present Absent Present Absent
Strength______L Radial L Pedal
B.P.______Pulse Rate______Apical rate______
S1 S2 S3 S4

none Pitting Non-pitting Location ______
Telemetry Rhythm (if applicable) ______
Other observations:______
Plan: ______
______

Respiratory

Effort
Breath sounds
Cough/Sputum
/ Rate____ Respirations even, regular, & unlabored SPO2 ___ room air SPO2 ___ via _____@__L/min

Clear Diminished Crackles Rhonchi Wheezes Absent
Location of adventitious sounds:______

None Nonproductive Productive Sputum (describe)______
Other observations:______
Plan: ______
______

Gastrointestinal

Diet/swallowing
Comfort
Abdomen
Bowel sounds
Tubes
Elimination / Diet type ______%taken NPO Dysphagia ______Enteral feeding____ml/hr

Tolerates diet well Nausea Emesis (describe)

Soft Hard Firm Distended Tender

Active in all quads Hypoactive Hyperactive Absent State location:______

None N/G Salem Other: ______Ostomy (type)______Describe drainage: ______

BM this shift (describe) ______Constipation Diarrhea
Other observations:______
Plan: ______
______

Renal/Urinary

Voiding/pattern
Urine
Diversion /
Without complaints Dysuria Incontinent Condom Indwelling urinary catheter Suprapubic
Amount:______Color: ______Clarity:______Sediment:______
Other observations:______
Plan: ______
______

Musculoskeletal

Movement
ROM
Assist devices
Activity
Feed/Bath
Turn/Oral / Strength/movement equal Flaccid/weak: Rt___ Lt____ Tolerates activity well Other______
Full active Passive Restricted______Immobile______
Contractures ______ Hip precautions
None Cane Crutches Walker W/C CPM Venodyne/SCD/Pneumonatic boots
Ambulates by self Ambulates with assist Up in chair Other:______

No assistance required Fed with assistance Fed by staff Partial bath Complete bath
Turn with partial assist Turn with max. assist Oral care with assist Oral care by staff
Other observations:______
Plan: ______
______

Integumentary

Appearance
Incision
Dressing / Warm Dry Skin color appropriate Cool Diaphoretic Pale Flushed Cyanotic Jaundiced
Intact Redness/Rash Lesion/Wound (describe)______
______
None Approximated Clean Dry Staples in place Reddened
Open Swollen
None Yes/Location______
Dry Drainage(describe)______
Other observations:______
Plan: ______
______

Reproductive (complete on all patients)

/ Birth control method______Last menses______Last PAP smear ______

None Itching Bleeding Discharge (describe)______Pain Breast lumps
Pregnant SBE STE Last mammogram______Last testicular exam______Rectal______
Other observations:______
Plan: ______
______

Endocrine/

Metabolic

/ Temperature ______Height______Weight______Blood glucose______
Polyuria Polydipsia Polyphagia Heat intolerance Cold intolerance Nervousness
Other observations:______
Plan: ______
______

Psychosocial

Emotional status
Support/Coping
Care participation
Code status /
Calm Anxious Depressed Irritable Frightened Aggressive Other:______

Coping/support systems adequate Family/friends visit Visit by chaplain Sacraments of the sick
Support system:______
Active Passive Non-compliant Non-responsive
Full Code No Code Limited Code______
Concerns related to hospitalization:______
Other observations:______
Plan: ______
______

Risk I.D.

Precautions
Siderails/Safety
/ Skin breakdown Falls Patient checked q1hr Restraints Type ______
Respiratory Contact Neutropenic

All down Top rails up Top & bottom up Bed in low position Call bell within reach brake on
Other observations:______
Plan: ______

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