SouthvilleInternationalSchooland Colleges

College of Nursing

GUIDE FOR ON-GOING ASSESSMENT IN CLINICAL SETTING

ACTIVITY / Type of Activity / BR / VASCULAR ACCESS / IV #1
Dangle
Chair / IV #2
Amb
BRP / IV #3
BSC
How Accomplished / Self / SAFETY / Bed in Lowest Position
With Asst
Turn and Position / Self / Call Bell Within Reach
Q2o Assisted / Seizure Precautions
RangeofMotion / Passive / Aspiration Precaution
Active / Initials
Deep Breath and Cough
HYGIENE / Bed Bath, Shower
(Circle One) / Self / SKIN BREAKDOWN SCREEN/BRADEN SCALE
With Asst
Complete / Sensory Perception
Ability to respond to
Discomfort / 1. Completely limited
2. Very limited
3. Slightly limited
4. No impairment
Oral Care
Peri Care
Sitz Bath
Cath Care (Q Shift) / Moisture – degree to which skin is exposed to moisture / 1. Constantly moist
2. Very moist
3. Occasionally moist
4. Rarely moist
Linen Change
PM Care
NUTRITION / Meals Taken By / NPO / Activity – degree of physical activity / 1. Bedfast
2. Chairfast
3. Walks occasionally
4. Walks frequently
Self Feed
Asst/Supervision
Total Feed
Amount of Meal(s) Taken / 100% / Mobility – ability to change and control body position / 1. Completely
immobile
2. Very limited
3. Slightly limited
4. No limitations
50%
Less than 50%
Supplements Taken / Per Order
Refused
ELIMINATON / Urine / Void ad lib / Nutrition – usual food intake pattern / 1. Very poor
2. Probably
inadequate
3. Adequate
4. Excellent
Foley Cath
Incont
Incontinent
Stools / Incontinent / Friction and Shear / 1. Problem
2. Potential problem
3. No apparent
problem
# of Stools
TUBES/DRAINS / Chest Tube
R or L / To suction
Off suction
Drains Type: ______ / Suction / Total Score
Clamped / Signature
NGT / Suction
Clamped
Placement/Residual
Suction (Enter # Times/Shift) / Trach
NT
Oral
Initials
DATE:
NEUROLOGICAL / No Problems Identified / Alert, oriented x3, speech clear, strength equal in all extremities, pupils equal and reactive
LOC /  Alert  Coma
 Lethargic  Obtunded
Orientation /  Person  Place  Time
Speech /  Clear  Untestable
 Slurred  Aphasic
 Mute
Dizziness /  No  Yes
Ataxia /  No  Yes
Pupil Reaction / R  Brisk  Sluggish  Fixed
L  Brisk  Sluggish  Fixed
Vision /  Clear  Blurred  Fixed
Extremity Strength / RUE  Strong  Weak  Flaccid
LUE  Strong  Weak  Flaccid
RLE  Strong  Weak  Flaccid
LLE  Strong  Weak  Flaccid
Neuro Comments
CARDIOVASCULAR / No Problems Identified / Normal heart sounds, regular rhythm, color pink, skin warm/dry, no edema
Rhythm /  Regular  Irregular
Heart Sounds / Normal  Abnormal
Skin Color /  Pink  Pale  Dusky  Flushed
Skin Temperature /  Warm  Hot  Cool  Cold
Edema /  None  Yes, location:______
Capillary Refill /  Brisk  Prolonged
JVD /  No  Yes
Pulses /  Radial and Pedal Pulses Present
 Abnormal Finding:______
CV Comments
RESPIRATORY / No Problems Identified / No distress, lungs clear bilaterally, no cough
Respirations /  No Distress  Dyspnea
Breath Sounds / R  Clear  Rhonchi
 Wheezes  Crackles
 Diminished  Absent
L  Clear  Rhonchi
 Wheezes  Crackles
 Diminished  Absent
Cough /  None  Dry  Productive
Sputum /  None  Clear  White  Green
 Yellow  Brown  Bloody
O2 Device /  None  NC  Mask  Collar
Artificial Airway /  None  Trach
Respiratory Comments
DATE:
GASTROINTESTINAL / No Problems Identified / Bowel sounds normal, abdomen soft, non-tender and non-distended
Abdomen /  Soft  Firm  Hard
 Non-tender  Tender
 Non-distended  Distended
Bowel Sounds /  Normal  Hypoactive
 Hyperactive  Absent
Nausea /  No  Yes
Vomiting /  No  Yes
Stool /  Normal  Constipation
 Diarrhea  Tarry
 Incontinent  Bright Red
GI Tube Type
Ostomy Type
GI Comments
GENITOURINARY / No Problems Identified / Urine clear/yellow, denies any reproductive problems
Urine Color /  Yellow  Amber  Bloody
Character /  Clear  Cloudy  Clots
Voiding /  Contingent  Incontinent
 Frequency  Urgent
 Burning  Anuria
GU Tube Type /  Foley  Suprapubic
 External  Urostomy
Female Vaginal Drainage /  No  Yes ______
Male Penile Discharge /  No  Yes ______
GU Comments
PSYCHOLOGICAL / No Problems Identified / Normal affect, intact thought processes, understands hospitalization/tx
Affect/Mood /  Normal  Angry/Hostile/Agitated
 Flat/Withdrawn  Unable to
assess
Thought Processes /  Intact  Unable to assess
 Abnormal Finding: ______
Insight /  Understands hospitalization/tx
 Does not understand
hospitalization/tx
 Unable to assess
Psych Comments

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