Southville International School and Colleges

1281 Tropical Ave. corner Luxembourg St., BF International, Las Piñas City
Tel. No.: 825-6374, 820-8702 to 03; Fax No.: 820-8715

SISC/QSF-NSG-068 Rev 000 4/19/10

COLLEGE OF NURSING

Name of Student: _______________________________ Level: _____________ Inclusive Dates: _______________________________

Clinical Rotation at: _______________________________

ON-GOING ASSESSMENT IN CLINICAL SETTING

Patient’s Name: _________________________ (Initials Only) Allergies: ___________________________________
Attending MD: _______________________________________ Diagnosis: ___________________________________

VASCULAR ACCESS
BR IV #1
Dangle
Chair IV #2
Amb
Type of Activity
BRP
ACTIVITY

BSC IV #3

How Accomplished Self

Bed in Lowest Position

SAFETY
With Asst
Turn and Position Self Call Bell Within Reach
Q2o Assisted Seizure Precautions
Range of Motion Passive Aspiration Precaution
Active Initials
Deep Breath and
Cough
Bed Bath, Shower Self
SKIN BREAKDOWN SCREEN/BRADEN SCALE
(Circle One) With Asst
Complete 1. Completely limited
Sensory Perception
HYGIENE

Oral Care 2. Very limited

Ability to respond to
Peri Care 3. Slightly limited
Discomfort
4. No impairment
Sitz Bath
Cath Care (Q Shift) DATE: 1. Constantly moist
Moisture – degree to
Linen Change No Problems  2. Very moist Bowel sounds normal,
which skin is exposed to abdomen soft, non-tender and non-
Identified
PM Care 3. Occasionally moist
moisture distended
4. Rarely moist
NPO Abdomen  Soft  Firm  Hard
1. Bedfast
 Non-tender  Tender
GASTROINTESTINAL

Self Feed Activity – degree of 2. Chairfast

Meals Taken By  Non-distended
3. Walks  Distended
occasionally
Asst/Supervision physical activity
NUTRITION

Bowel Sounds  Normal  Hypoactive

Total Feed 4. Walks frequently
 Hyperactive  Absent
100% Nausea 1. Completely
 No  Yes
Amount of Meal(s)
50% Mobility
Vomiting– ability to  No immobile  Yes
Taken
Less than 50% change 2. Very limited
Stool and control body Normal  Constipation
Per Order position  Diarrhea  Tarry
3. Slightly limited
Supplements Taken  Incontinent  Bright Red
4. No limitations
Refused
Void ad lib GI Tube Type 1. Very poor
ONELIMINAT

Foley Cath 2. Probably

Nutrition – usual food
Ostomy Type
Urine Incont inadequate
intake pattern
Incontinent 3. Adequate
GI Comments
4. Excellent
Incontinent No Problems  1. Problem Urine clear/yellow,
Stools Identified denies any reproductive
# of Stools 2. Potential problem problems
Friction and Shear
Chest Tube To suction 3. No apparent
Urine Color  Yellow  Amber  Bloody
problem
R or L Off suction
GENITOURINARY

Character  Clear  Cloudy  Clots

TUBES/DRAINS

Suction Total Score

Voiding  Contingent  Incontinent
Drains Type: _______
Clamped Signature  Frequency  Urgent
Suction  Burning  Anuria
NGT Clamped NOTES:
GU Tube Type  Foley  Suprapubic
Placement/Residual  External  Urostomy
___________________________________________
Suction (Enter # Trach Female Vaginal  No  Yes ___________________
____________________________________________
Drainage
____________________________________________
Times/Shift) NT
Male Penile  No  Yes ___________________
Oral ____________________________________________
Discharge
Initials ____________________________________________
GU Comments
____________________________________________
_______________________________________________________________________________________________________
No Problems  Normal affect, intact
_______________________________________________________________________________________________________
Identified thought processes, understands
hospitalization/tx
A LP S Y C H O L O G I C

DAILY GUIDE: Affect/Mood  Normal  Angry/Hostile/Agitated

 Flat/Withdrawn  Unable to
Day 1 → Assessment, Gather Data – Identifying Problems Assess
Day 2 → On-going Assessment – Prioritize Problem – Set Goals – Interventions  Intact  Unable to assess
Day 3 → On-going Assessment – Interventions – Outcome/Evaluation Thought Processes  Abnormal Finding: _______________
Insight  Understands hospitalization/tx
DATE:
 Does not understand
hospitalization/tx
 Unable to assess

Psych Comments
 No Problems  Alert, oriented x3,
Identified speech clear, strength equal in all
extremities, pupils equal and reactive
LOC  Alert  Coma
 Lethargic  Obtunded
Orientation  Person  Place  Time
NEUROLOGICAL

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
No Problems  Normal heart sounds,
Identified regular rhythm, color pink, skin
warm/dry, no edema
CARDIOVASCULAR

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
No Problems  No distress, lungs clear
Identified bilaterally, no cough
Respirations  No Distress  Dyspnea
R  Clear  Rhonchi
 Wheezes  Crackles
RESPIRATORY

 Diminished  Absent
Breath Sounds
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

HIGHLY PRIORITIZED
Nursing Problem: ______________________________________________________________________________
CARE PLAN
Nursing Diagnosis Related Drug Related Lab Short Term Goal Nursing Intervention Evaluation/Outcome
Therapeutics Diagnostics

CRITERIA: Content / Completeness - 45% Accuracy - 40% Punctuality - 15%