Southville International School and Colleges - DOC

							Southville International School and Colleges
College of Nursing
GUIDE FOR ON-GOING ASSESSMENT IN CLINICAL SETTING
BR Dangle Chair Amb BRP BSC Self With Asst Self Q2o Assisted Passive Active IV #1 VASCULAR ACCESS SAFETY Initials IV #2

Type of Activity ACTIVITY

IV #3 Bed in Lowest Position Call Bell Within Reach Seizure Precautions Aspiration Precaution

How Accomplished Turn and Position Range of Motion Deep Breath and Cough Bed Bath, Shower (Circle One) Oral Care Peri Care Sitz Bath Cath Care (Q Shift) Linen Change PM Care

Self With Asst Complete

SKIN BREAKDOWN SCREEN/BRADEN SCALE Sensory Perception Ability to respond to Discomfort Moisture – degree to which skin is exposed to moisture 1. Completely limited 2. Very limited 3. Slightly limited 4. No impairment 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist 1. Bedfast 2. Chairfast 3. Walks occasionally 4. Walks frequently 1. Completely immobile 2. Very limited 3. Slightly limited 4. No limitations 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent 1. Problem 2. Potential problem 3. No apparent problem

HYGIENE

Meals Taken By NUTRITION

Amount of Meal(s) Taken Supplements Taken

ELIMINATON

Urine

NPO Self Feed Asst/Supervision Total Feed 100% 50% Less than 50% Per Order Refused Void ad lib Foley Cath Incont Incontinent Incontinent # of Stools To suction Off suction Suction Clamped Suction Clamped Placement/Residual Trach NT Oral 1

Activity – degree of physical activity

Mobility – ability to change and control body position

Nutrition – usual food intake pattern

Stools Chest Tube R or L

Friction and Shear Total Score Signature

TUBES/DRAINS

Drains Type: _______ NGT Suction (Enter # Times/Shift)

Initials

DATE: No Problems Identified LOC Orientation Speech  Alert, oriented x3, speech clear, strength equal in all extremities, pupils equal and reactive  Alert  Lethargic  Coma  Obtunded

Dizziness Ataxia Pupil Reaction Vision Extremity Strength

 Person  Place  Time  Clear  Untestable  Slurred  Aphasic  M ute  No  Yes  No  Yes R  Brisk  Sluggish  Fixed L  Brisk  Sluggish  Fixed  Clear  Blurred  Fixed RUE  Strong  Weak  Flaccid LUE  Strong  Weak  Flaccid RLE  Strong  Weak  Flaccid LLE  Strong  Weak  Flaccid

NEURO L OG ICAL

Neuro Comments No Problems Identified CARDIO VASCUL AR Rhythm Heart Sounds Skin Color Skin Temperature Edema Capillary Refill JVD Pulses CV Comments No Problems Identified Respirations  No distress, lungs clear bilaterally, no cough  No Distress  Dyspnea R  Clear  Rhonchi  Wheezes  Crackles  Diminished  Absent L  Clear  Rhonchi  Wheezes  Crackles  Diminished  Absent  None  Dry  Productive  None  Clear  White  Green  Yellow  Brown  Bloody  None  NC  M ask  Collar  None  Trach  Normal heart sounds, regular rhythm, color pink, skin warm/dry, no edema  Regular  Irregular  Normal  Abnormal  Pink  Pale  Dusky  Flushed  Warm  Hot  Cool  Cold  None  Yes, location:___________  Brisk  Prolonged  No  Yes  Radial and Pedal Pulses Present  Abnormal Finding:_______________

RESPIRATO RY

Breath Sounds

Cough Sputum O2 Device Artificial Airway Respiratory Comments

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DATE: No Problems Identified Abdomen G ASTRO INTESTINAL  Bowel sounds normal, abdomen soft, non-tender and nondistended  Soft  Firm  Hard  Non-tender  Tender  Non-distended  Distended  Normal  Hypoactive  Hyperactive  Absent  No  Yes  No  Yes  Normal  Constipation  Diarrhea  Tarry  Incontinent  Bright Red

Bowel Sounds Nausea Vomiting Stool

GI Tube Type Ostomy Type GI Comments No Problems Identified Urine Color Character Voiding  Urine clear/yellow, denies any reproductive problems  Yellow  Amber  Bloody  Clear  Cloudy  Clots  Contingent  Incontinent  Frequency  Urgent  Burning  Anuria  Foley  Suprapubic  External  Urostomy  No  Yes ___________________  No  Yes ___________________

G ENITO URINARY

GU Tube Type Female Vaginal Drainage Male Penile Discharge GU Comments No Problems Identified

PSY CHO L OG ICAL

Affect/Mood

Thought Processes Insight

 Normal affect, intact thought processes, understands hospitalization/tx  Normal  Angry/Hostile/Agitated  Flat/Withdrawn  Unable to assess  Intact  Unable to assess  Abnormal Finding: _______________  Understands hospitalization/tx  Does not understand hospitalization/tx  Unable to assess

Psych Comments

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