BERGEN COMMUNITY COLLEGE

DEPARTMENT OF NURSING

CLINICAL ASSESSMENT TOOL

 

 

 

 

Subjective Data (Basic Conditioning Factors)

 

Student:                                                            Date of Care:

 

Patient’s Initials:                                      Age:

 

Room #:                                                           Allergies:

                                                                        Food:

Gender:                                                            Medications:

                                                                        Environmental:

 

Admitting Diagnosis:

 

 

 

 

Secondary Diagnosis:

 

 

 

Developmental Stage (Erickson and Havinghurst, see Perry and Potter):

(List Developmental stage and tasks, assess each task)

 

 

 

 

History of present illness:

 

 

 

 

Past medical history (Include Date):

 

 

 

 

Past surgical history (Include Date):

 

 

 

 

Medications:

Drug Name                  Dose                Route               Frequency                   Classification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complementary/Alternative Medical Practices

 

            Herbal Remedies:

 

            Vitamins/Minerals:

 

            Meditation/Yoga

 

            Massage:

 

            Acupuncture/Acupressure:

 

            Aromatherapy:

 

            Other:

 

 

Health care system (Current orders and role of health care members):

 

 

 

 

 

Sociocultural / spiritual orientation:

 

 

 

 

 

Family system:

 

 

 

 

 

Patterns of Living:

 

A. Employment:

 

 

B. Education:

 

 

C. Hobbies / interest:

 

 

D. ETOH / drug use

 

 

Environment (Conditions of living and working):

 

 

 

 

Available Resources (Economic, personal, agencies):

 

 

 

 

Laboratory and Diagnostic Test (give results and significance of abnormals)

 

 

 

 

 

 

 

Objective Assessment of the USCR's

 

Please use Y, N, NA to indicate Yes, No or Not Applicable

 

 

Day 1

Day 2

Additional Data

 

Psychosocial
Solitude v. Social Interaction or
Normalcy

 

 

 

 

Well groomed/Good hygiene

 

 

 

 

Appropriate/Full range affect

 

 

 

 

Maintains eye contact

 

 

 

 

Calm mood

 

 

 

 

Cooperative attitude

 

 

 

 

Able to concentrate

 

 

 

 

Clear speech (volume/tone)

 

 

 

 

Psychomotor retardation

 

 

 

 

Tics/Tremors

 

 

 

 

Hyperactivity/Restlessness/Agitation

 

 

 

 

Hallucinations/Illusions

 

 

 

 

Suicidal/Homicidal Ideations

 

 

 

 

Activity/Rest

 

 

 

 

Well-rested

 

 

 

 

Fatigued

 

 

 

 

Slept through night

 

 

 

 

Neuromuscular
(prevention of hazards)

 

 

 

 

Alert and oriented

 

 

 

 

Gait steady

 

 

 

 

Hygiene independent

 

 

 

 

Pain free

 

 

 

 

Hand grasp,
strong and equal bilat

 

 

 

 

Foot push,
strong and equal bilat

 

 

 

 

Smile symmetrical

 

 

 

 

Tongue to midline

 

 

 

 

PERL

 

 

 

 

Meets developmental task

 

 

 

 

Cardiovascular

(air or water)

 

 

 

 

Palpable pedal pulses bilaterally

 

 

 

 

Oral mucosa pink

 

 

 

 

Conjunctiva pink

 

 

 

 

Capillary refill within 2 seconds

 

 

 

 

Absence of edema

 

 

 

 

Apical/radial regular rhythm

 

 

Rate=

 

Blood pressure

 

 

BP=

 

Telemetry

 

 

 

 

Integument

(prevention of hazards)

 

 

 

 

Temperature

 

 

Temp=

 

Skin turgor WNL

 

 

 

 

Skin warm to palpation

 

 

 

 

Skin intact

 

 

 

 

Incisions

 

 

 

Wounds

 

 

 

 

 

 

 

Day 1

Day 2

Additional Data

Respiratory
(air)

 

 

 

 

Resps easy and even

 

 

 

 

Lungs clear

 

 

 

 

Secretions

 

 

 

 

Oxygen in use

 

 

 

 

Oxygen saturation

 

 

 

 

Cough and deep breathe

 

 

 

 

Chest tubes

 

 

 

 

Gastrointestinal
(Food or Elimination)

 

 

 

 

Abdomen soft

 

 

 

 

Abdomen non-distended

 

 

 

 

Bowel sounds present

 

 

 

 

Abdominal drains

 

 

 

 

Stomach tubes

 

 

 

 

Bowel movement

 

 

 

 

Nausea/vomiting

 

 

 

 

Feeds self

 

 

 

 

Breakfast (% consumed)

 

 

 

 

Lunch (% consumed)

 

 

 

 

Dinner (% consumed)

 

 

 

 

Tube feeding

 

 

 

 

IV solution (type and rate)

 

 

 

 

IV site (location)

 

 

 

 

IV site without redness or swelling

 

 

 

 

IV dressing dry and intact

 

 

 

 

Chemstick

 

 

 

 
Genitourinary

(Fluid or Elimination)

 

 

 

 

Voids in bedpan or bathroom

 

 

 

 

Foley catheter

 

 

 

 

Suprapubic tube

 

 

 

 

Urine clear

 

 

 

 

Color yellow-amber

 

 

 

 

Amount (cc's)

 

 

 

 

Continuous bladder irrigation

 

 

 

 

Lab Data (explain abnormal values)

 

 

RANGE

 

WBC:

 

4.5

 -

11.0

 

HGB:

Men

14.7

 -

16.1

 

 

Women

12.0

 

16.0

 

HCT:

Men

42.0

 -

52.0

 

 

Women

37.0

 

47.0

 

Platelet

 

150.0

 -

450.0

 

Glucose

 

70.0

 -

110.0

 

Sodium

 

135.0

 -

145.0

 

Chloride

 

95.0

 -

110.0

 

Potassium

 

3.5

 -

5.1

 

Calcium

 

8.4

 -

10.2

 

Albumin

 

3.4

 -

5.0

 

BUN:

 

7.0

 -

20.0

 

CR:

 

 

 -

 

 

PT:

 

 

 -

 

 

PTT:

INR:

 

 

 -

 

__________________________________________________

CK:

 

 

 -

 

 

Troponin                                                          ___________________________________

 

NURSING DIAGNOSIS (USE P (problem).E (etiology).S (symptoms).FORMAT):

P:

 

 

E:

 

 

S:

 

 

 

INTERVENTION #1:

 

 

 

INTERVENTION #2

 

 

INTERVENTION #3

 

 

 

                                                            OR

NURSING DIAGNOSIS IN EACH AREA BASED ON PATIENT ASSESSMENT:

 

NEUROMUSCULAR (prevention of hazards):

 

 

CARDIOVASCULAR (air or water):

 

 

INTEGUMENT (prevention of hazards):        

 

 

RESPIRATORY (air):

 

 

GASTROINTESTINAL (food or elimination):  

 

 

GENITOURINARY  (fluid or elimination):