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Clinical packet 6
Fundamentals (NUR155)
Galen College of Nursing
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r = fl FUNDAMENTALS ASSESSMENTS
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####### FUNDAMENTALSISBARR
!DENTIFICATION: (Patient Demographics) Date:lziTime: I0
####### Room# 520
Age: C(.Q Sex:M,(e}
Weight: :;le.~ Kg Height: 5-f'+-
Physician: \den Nurse:
t\e,\d ionct.
Aid: C,\aud,0-
Family contact: \J/-A
□Advanced Directive ~ { A-
SITUATION: (Patient's current status)
Date of Admission: 51 'J. 'l. 4 Admitted From: o ..3'.:wd Re
Mod.. T<l
Admitting Diagnosis: μv.--,f> \e. F ~ o-r Pe'", s s d \S'<Of' of'""(.,
(,
Status: □Full Code DNR □Elopement D Other:____
_
Vital Signs: 8/P:'' HR:-=l-0 RR: \ 1, Sp02:·tRoomAir □ 02 at_L
via__
Temp:q\i•FgtTemporal D Oral OTympanic
BACKGROUND: (Patient'shistoryrelevant to currentcare needs)
Allergies: D Latex ~ Other: D NKDA
PastMedical/Surgical
History:C,KD ~-+e.. 3AJGERD, RQdlodcrroifcl:is,Afib
-
Isolation Precautions: [XI Standar OC-Diff D Contact:
Safety Precautions: D Aspiration ®Fall D Seizures
D Other: tJ-----t--'-/A_______________
_
Additional Safety concerns/interventions: ~ Assistive Devices: D None~Walker D Cane D Wheelchair □ 0th er: £:-uo± w½ee\ed l>. w ¼-ex MA.□ HearingAidS:(se/ectone) □Right □Left □Bilateral □Dentures: (select one) □Upper □ Lower AOL Assist: \0 /. , Hygiene: O • , Nutrition: O ·; 0 □Both )A
####### l ~ C 1 f ::
ASSESSMENTS: (Brief review of body 5 Y 5t ems) Alert Oriented to: ~ Person ·- Pl;,c(l lxJ llma
- Sltuotlan Neurological
- Room Air O 02 via:NC Mask__L/min Respiratory Cardiovascular GI GU Pacemaker D Other:
####### Diet: Mecno, co..\ ~o--H" D FBS
- Brief O Foley catheter O Purewick
O Independent D BSC □condom
□ Ambulatory As •·
No,n-ambulatory 1 ,MusculoskeletaI-----~~~-::-~~~~ d t-Skin '/. 2 \eG\o (llA °'L ~ ILLE y.?)leS, BECOMMENDATION:(NextSteps,areas offollow up, open orders, RN/LPNsdonot writemedical orders) Outstanding Orders: No OLLto~ orders READ BACK: (Verify understanding)
StudentNurse~ ~Jh.\IJ, S W,
####### Signature/Date/TimC.J,D,t/'--S h?h Lj \L\ ;:SO
-
p
J
7
)
GALEN FUNDAMENTALS ASSESSMENT
DfMO0rtJ\JfHIC~ MmltltnnDIIJIM'"Mv-~~ {1 o pclS- -- Mf,.,v• \fg hMJb)otl'
H,icht 5-£.i: VJ,-11111 ~.5 ~ Sa,,,_f- l'JJII MrdkJtl/Sur1lceJ ~,,10,y Jl10:Jn~~or, T ~ Hamd~
,-
Pc.\C.'f r.~
Cod" Stntui:1s1.,c11 O;ulf codr Qfor-m CJcm,,,,__________/.{Jv;ncnrf o1r.-crm _fJfJ 11
lsol
'' tnhotlonProcoutlons: r~~ctJ IJS-t,ndard □conl □CoY1uc1/C DllrO0,oplrt00thar---------------
Attlvlty, ~o:JMs_4,\lflL11lt{a.-9V -- Diet• Mcci1_a Serl f
Vital Sign,, 0;11c,/llmc .tiJi!j=-Dl 15 Poln__ 07[ - -
U/P 1(0 f-=tQ RUE'HA -=tO RR L'b _Sr,02 q;,/• (Scl,.ctonc)5'toamAlr □rK D,A,uht_l/m
f Pmp _9_3:,fr (Sclr) ■Trmpor•I □orol CAxfllnr•1 a Tvmpanfc
NEUROLOGICAL ASSESSMENT
0rlt'nfed to 11( Porson ficPlaco{rtma 'lit SftuatJon L,ivel ot Consdousneu Rf Alert
OLatlmg1c □Stupor CJUnresponslve
Communluitlon· Q{VP CommunlQUon □ Non verbal Communication D Dvrthrf11 D Receptive Aphas,a D(Jq,reSSNt AphJa
Puplls: (21 PERRLA OR PupllS1zeA l· Round[23 □ ,o Accommodation:□ Right D l,..(!ft
Reactivity to UghtRight,.Cl!3rl\l1 □Sluggish D No Reaction
Lcrt. r;Jts<tskOSluftl!lshD No fleoctlon
Respon to Commands: !Yj/ollows commands O Attempts to fallowc □ No attemptLafollow commands
LoQtfon. Mu~cfoS(r"nfth SensntJon Tremor
(SclP 0110 foreach (Sclocl one for e:ich loc:itfonJ (Select one
lot each location)
foca!lon)
- I Head/Neck M'Strong_OWcak grouch OParn only □No response to pain @'No □Present Right H (g'SrrongOwca~ IS(rouch OPalnonly ONoresponse to pain [B'No □Present lcf1 Hand 0 Strong izt'weak &'Touch □Pain only □No response to pain l'lJNo □Present Rlght U(: tg'Strong □Weak 62JTouch OPalnonly □No response to pain l§j!No □Present LoftUE: 0 Strong g'Wcak [SJ'fouch □Pain only □rfo response to pain (Y'No □Present Right LE 0 Strong~Weak ~'y)uch □Pain only □No response to pain [B'No □Present Lett lE• ~Strong □Weak (i'Touch OPalnonly □No response to pain ti}(/o □Pre Commcnu:
MUSCULOSKELETAL ASSESSMENT
Movement Full range of morion appropriate for)evelopmenlal age· Yes D
Developmentally Independent ambulatlon: &J Ye§ ONo Dcscrfbe.
No Describe:= l'E ( h o
co o-\Y'Clc-tu. -(.
Asslstlve Ambul11tlon Devices:
Gait, (select one} OL1mp L □Non-Ambulatory
Comment
ll
RESPIRATORY ASSESSMENT
OxyBanalfonStatus02 G-3_:', (Sclccl on,.) r,LRoom Air □NC□Mask
:nt_Umln RR
Couehi(Selectone) one □Non•Produttlvo OProducllvr Sputum o,~~crlptlon
~
R1•1ph11to,y(ffon l1f Evcn/UnJabort'd OLaborod 0l?icrlbo
Rosr,lratory Pottem ,Pilftcgular Olrrcnulor (Selectpnttcrn1rf,rogularl
ornchypnPn □Bradypn□Hyperventilllllon OHypovorrtllatlon
DroaihSounds1 Areas AtnC!(Select)OAntcraor □Posterior f!lDoth
RUL lifClaarthroughout d 0ncreased DFineCrocklesOCoursoCrackles D Wheezes
□Friction Rub ORhonchl □Ab~~mt
RMLIfOour throughout DDccrc11sed □Fino CracklesOcoursoCrnckll!S D WhcOZl!S
□FrlcUon Rub ORhonchl □Absent
fill fmclet1r throuilhout □Decreased □Fine Cr~ □course Crnckles D Wheezes
OFrlctlonRub ORhonch1OAbse?n
BreathL so und. s. Aro Auscultated•(Select) □Anterior□PosteriorD Oath
UL '81 Clearthroughout □Decrcad □Fine Crackles □Course CracklesO Wheezes
□Friction Rub ORhonchl 0Ab,ent
RLL R(cleor throughout □Decreased Oi:ineCracklesOcoueCrackles Owheczc
□Friction Rub ORhonchl □Absent
Com mJ?nts.
GASTROINTESTINAL ASSESSMENT
Abdomen: (Select apphcable) □Mass O wlons OD1stenslon OTendl?rness
Bowel Movements. Date oflast bowel movement Comments;
Continence: Continent of stool Olncontlncnt of stool
Meth0 d of Output: ollet OBedsJde Commode C]Bedpan rief Oostomy
Nausea/Vomiting. None □Present Describe· (color/amount/co11Slstency/frequcncy)· -----------------
Bowel Sounds· (Select one)
RUQ 81Active □Hyperactive □Hypoactive □Absent (after S full minutes)
LUQ ll!II Active D Hyperactive D Hypoactive D Absent (after 5 full minutes)
RLQ IJAcllve rd OHvperact1ve OHypoactlv,. " □Absent ( a"erc. 5 fuII mrnutes)
LLQ '-"Active D Hyperactive D Hypoactive D Absent (after 5 full minutes)
Tube Feeding: LSNone OG-Tube DNGTube Methodofplacement venricat,on·
Sloma: None D Pink □Deep Red □Dusky □Retracted Ostomy care:
Comments:
Output Subnnce
f urin/l!mcsh/othcr)
Tot~
INTAKE/OUTPUT
uromcntml)
Unitormeasurem1int
1ml or II voids.E
lntalu: RoutaPO,Entc,rnl,IV
CollcctlonMethod
(Olt. Tollol h:it,folf"'t)
GENITOURINARY ASSESSMENT
.
Urination ~ '10 \ ci.
Urine Characterlstfe!. qe,\ \ovJ I c\co. ( I "'t)
Oc\ O(
Continence JQContlnl!nt of urine □rncontlncnt or urine ,I
MethodofOutput• □Tollet O BedsideCommode
□Bedpan p;Jerlef Oostomy OPurwlck
OCntheter
Catheter:~one □Foley □Condom
Comments:
NURSING NOTES (SOAP,SOAPICSOIIPICllOM,OJ\C,JllCSfiAn) Sign r11ch notowllh rumo, d,Hc, and limo Mor,,lnaCara Provldcli
####### 0100: \JS 5~0S LOrop\ciLd_,~ ,0L, Ass·~~ AD\·-~Assis11'd
.&fr- Y'l-.§UcW....:.-•------------------
0750: wa,(.gd v:>t4-\t\ Men:: :-0 cl,ot:0901ea:!,_______
Q30o·. Pr w·,.-v\ ph.'l\cu.\ t:Y)l<--------------
,00:
Slanatura/Dota/TlmaciA& ~. ~tJ ~}t...;;...?-1\2,..-.!...::::.,:03Q==---------
AfternoonCnrcProvided,
Slgnaturc/Date/Time__________________________
Closing Note ...._____
-----
Signature/Dote/TIme
LaboratoryResults: (N/AIfnolaboratoryresults available)
Test Date Result Normal? Indication for this lab order Primary/SecondaryBody Systems
we,c.. '5/2-3 7-~ u)..- lrr<c\on {lL
ROC 5126124 3.?> Low \0- N\(\,.L~+,(:)('
5}Z3J2y \L\ I lA),) L. -\ 'I ~r-kncs\ of"\ c.,°'c.. ~ ~~
':6lua sI2 ?>,i v.))-.\L- \ ! Sien Card\o.. S 5-\c_\
NurS('s o+e:.
2-,u.,&#039;--,
'5~----------
5/23 f202y
\
BRADEN SCALE - For Predicting Pressure Sore Risk M SEVERE RISK: Tout score S 9 HIGH RISK: Tomi score 10-12 1!!1111-. ODERATE RISK: TotJI acore 13•14 MILD RISK: Total score 15- RISI< FACTOR llA It. Ur• ASSESS•
Iliff~ -• a· 11!:
PERCEPTION Ability to respond me11ntn1fully to prossure-rrlotl!d discomfort - CO I> E 0 Dl!grea to which skin b l!lCPOM!ld lo moisture Degree of physlcnl nctlvlty MO Ablllty to change ond control body poslUon NUTRITIO Usual food Intake pattern 1 NPO: Nothing by 1 mouth. 1V: Intravenously. srPN:Total parenteral nutrition. FRICTION AND SHEAR TOTAL SCORE LIMITED- Unrnponslvc (doet not moan, flinch, or 1r1sp) to painful sUmuU, due to dlmlnlsh11d level of consclousneu or sedition, OR llmlted ability to feal pain over most o( body aurfac, l. MOIST-Skin Is ktpt moist almost constantly by porsplraUon, urine, etc. Dampness Is datectl!d every tlmo patient Is mowd or tutnod.
- oc1Jr,.~ - Confined to bed. l. CO V IMMOBILE- Does not make even slight chanaes In body or extremity position without assistance. RY POOR- Never eats a complete meal. Rarely eats more than 1/ of any food offered. Eats 2 servings or less of protein (meat or dairy products)perday fluids poorly. Does not take a llquld dietary supplement, OR Is NP0 1 and/or maintained on dear liquids or IV for more than 5 da l. PROBLEM• Requires moderate to maximum assistance In moving. Complete llhlng without sliding against sheets ls Impossible. Frequently slldes down In bed or chair, requiring frequent repositioning with maximum assistance. Spastlclty, contractures, or agitation leads to almost constant friction. SCORE/DESCRIPTION . ER Ml [f:f• Rtttponds only to painful 1Umull. C. communicate dlscomfort cltCt1pt by moa nln1 or rC?Stlauness, OR has D sensory Impairment which limits the 1blllty to feel pain or dlst0mfort over K of body, , SU TL LIM l D - Rirspond1 to 11etb1l commands but annot always communicate dlscomrort nr need to b turned, OR has M>mO sensory lmp1lrmant which Omits ability to fctel pnln or dlicomfort In 1 or 2 ewtrcmltles. •. M ,.. ftJIIOMT l\aponds to \ll!fbal comm ■ ndl. Hu no lffl'IIO,V dendt whlc would limit Dbfllty to foci or voice pain or dl!.COmfon,
- 0 -Skin Is often but not 1twavs moist. Unen must be chanaad at least onco • shlfL
- MOIST - Skln 1, ocallonally moist, rciqulr1ng 11n extra llnC!n ch11n1e approxlmately once a d1y. Di--------~ 4 ...... .,... L" - - Skin 1, usually dry; linen only requires changing at
routine Intervals. ••••
- AIR - Ability to walk ,everelv limited or nonexistent. cannot IMtar own welaht and/or must be assisted Into chair or wheelchair. 2.. LI I Makes occaslonal slight changes In body or extremity position .but unable to make frequent or st1nlfle1nt changes lnde endentl. 2. ROBAB INADEQUATE - Rarely e11ts a complete meal and generally eats only about ~ of any food offered. Protein Intake Includes only 3 servings of meat or dairy products per day. Occasionally wlll take a dietary supplement OR receives less than optimum amount of liquid diet or tube feedln. 2. POTENTIAL PROBLEM- Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position In chair or bed most of the time but occaslonally slides down. 3. A OCCASIONALLV-Walks ocaslonally durlns day, but for very short dl1tance1, w:lth or without assistance. Spends ma)Ofltv of each shift In
"·FREQUENTLY-Walks
outsldct the room at least twice I day and Inside room at lent once every 2 hours during waking hours.
••••
bed OT chair. 3. T LIMI Makes frequent though illght changes In body or extremity position Independently. 3. Q ATE-Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occaslonally refuses a meal, but will usually take a supplement if offered, OR Is on a tube feeding or TPN 1 regimen, which probably meets most of nutritional needs. 3. NO APPARENT PROBLEM - Moves In bed and In chair Independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 4. NO LIMITA 10 Makes major and frequent changes In position without
assistance. ••••
- E CE LE -Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
••••
••••
Total score of 12 or less represents HIGH RISK EVALUATOR SIGNATURE~ DATE I I I I I I NAME-Last First Middle
\J~
Attending Physician
&\del)
Record No. Room/Bed Form 3166P HIGGS Oa Molne1, IA 503CMI (IOO) 247 -.lrlusCorp IUIM PI\INTED IN U.5 Source: Barbara Braden and Nancy Bergstrom. Copyright, 1988. BRADEN SCALE Reprinted with permission. Permission should be sought to use this tool at bradenscale U~ the form only tor the app~ purpose. Ally use of the form In publlatlons Iother than Internal poOcy manuals and lralnlna materlaO or for proRt-makln1 ven\Ulti ~ulres additional pmmslan anrl/or ne1otatlan.
Clinical packet 6
Course: Fundamentals (NUR155)
University: Galen College of Nursing
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