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Clinical Packet 8: Nursing Fundamentals Assessment Reflection
Fundamentals (NUR155)
Galen College of Nursing
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FUNDAMENTALS ASSESSMENTS FUNDAMENTALS ASSESSMENTS I a Assignment Making a difference in a life through caring and compassion is an important aspect of nursing. Compassionate interactions, active listening, and empathetic communication form the cornerstone of this approach, enabling nurses to address emotional and spiritual needs. This deep connection enhances patient and promotes dignity and hope, ultimately contributing to a more profound and positive healing experience. nursing significantly practice. impact lives, reflecting the true essence of Jean care, vision nurses for can In the Essence of Through such dedicated and compassionate On a wall on campus, there is a quote from the nurse theorist, Jean Watson, difference As a nursing student, you have the unique opportunity to make a profound in your life. Take Today a in clinical, focus on demonstrating caring and compassion in every patient interaction. being. sharing a genuine smile. can significantly impact their emotional and psychological or simply words. Small acts, such as holding their hand, ensuring they are comfortable, presence and understanding moment to listen actively to your concerns, offering n comforting care can recognizing foster their individuality, and addressing their holistic needs. Your dignity and respect, Reflect on Jean principles of human caring treating your patient with TR the essence a healing environment, bringing comfort and hope to your patient compassionate and reinforcing of nursing. patient Write a paragraph reflection on how you a in caring for assessment). today. This will be submitted with your clinical packet (in place of the psychosocial your solving been an issue with his urostomy connection. Patient I feel that I made a difference in my patients life SOI leaking and I noticed the connection secure adjusted it for him. He was so grateful . before he could even ask. I made his bed and handed him his paste I just talked to him majority of the time while I Cleaned up his room. we were laughing about how he like eating with the residents because they were grouchy. I told him to put a smile on and enjoy his breatfast. I feel I made a difference just talking to him and engaging in helping him getup for the day. I a Assignment Making a difference in a life through caring and compassion is an important aspect of nursing. Compassionate interactions, active listening, and empathetic communication form the cornerstone of this approach, enabling nurses to address emotional and spiritual needs. This deep connection enhances patient and promotes dignity and hope, ultimately contributing to a more profound and positive healing experience. nursing significantly practice. impact lives, reflecting the true essence of Jean care, vision nurses for can In the Essence of Through such dedicated and compassionate On a wall on campus, there is a quote from the nurse theorist, Jean Watson, difference As a nursing student, you have the unique opportunity to make a profound in your life. Take Today a in clinical, focus on demonstrating caring and compassion in every patient interaction. being. sharing a genuine smile. can significantly impact their emotional and psychological or simply words. Small acts, such as holding their hand, ensuring they are comfortable, presence and understanding moment to listen actively to your concerns, offering n comforting care can recognizing foster their individuality, and addressing their holistic needs. Your dignity and respect, Reflect on Jean principles of human caring treating your patient with TR the essence a healing environment, bringing comfort and hope to your patient compassionate and reinforcing of nursing. patient Write a paragraph reflection on how you a in caring for assessment). today. This will be submitted with your clinical packet (in place of the psychosocial your solving been an issue with his urostomy connection. Patient I feel that I made a difference in my patients life SOI leaking and I noticed the connection secure adjusted it for him. He was so grateful . before he could even ask. I made his bed and handed him his paste I just talked to him majority of the time while I Cleaned up his room. we were laughing about how he like eating with the residents because they were grouchy. I told him to put a smile on and enjoy his breatfast. I feel I made a difference just talking to him and engaging in helping him getup for the day. THE NUMSING ASSESSMENTS: (Brief review of body systems) Neurological Alert Oriented to Person Place Time Situation Respiratory Room Air 02 via: NC Mask Cardiovascular Pacemaker Other: GI Diet: CCHO FBS AM BS 115 GU urostomy Brief Foley Catheter Purewick Independent BSC Condom Musculoskeletal xl Ambulatory Assist Skin warm, dry, in stact ostomy site Intact, pinks, Tenderness present) None urostomy RLQ intact (site present ) RECOMMENDATION: (Next Steps, areas of follow up, open orders, do not write medical orders) Outstanding Orders: No outstanding orders Follow up Items: urostomy change PRN, check BS before meals empty PRN. urostomy if leaking inspect bag tubing for proper inspect skin connection Revaluate pain level PRN Clinical Concerns: urostomy leaking , fasting Am BS 115, skin integrity around urostomysite, muscle weakness, pain level Goal for Shift: maintain urostomy integrity frequent inspection Q2h for leakage. Inspect skin integrity at urostomy site Maintain BS for type 2 diabetes 126 to 200, monitor meal Evaluate pain level Qshift. consumption READ BACK: (Verify understanding) Student Nurse: Erin Yuslum ,SN. Evinyislen, SN 1300 Fundamentals Assessments Page 3 of 8 THE NUMSING ASSESSMENTS: (Brief review of body systems) Neurological Alert Oriented to Person Place Time Situation Respiratory Room Air 02 via: NC Mask Cardiovascular Pacemaker Other: GI Diet: CCHO FBS AM BS 115 GU urostomy Brief Foley Catheter Purewick Independent BSC Condom Musculoskeletal xl Ambulatory Assist Skin warm, dry, in stact ostomy site Intact, pinks, Tenderness present) None urostomy RLQ intact (site present ) RECOMMENDATION: (Next Steps, areas of follow up, open orders, do not write medical orders) Outstanding Orders: No outstanding orders Follow up Items: urostomy change PRN, check BS before meals empty PRN. urostomy if leaking inspect bag tubing for proper inspect skin connection Revaluate pain level PRN Clinical Concerns: urostomy leaking , fasting Am BS 115, skin integrity around urostomysite, muscle weakness, pain level Goal for Shift: maintain urostomy integrity frequent inspection Q2h for leakage. Inspect skin integrity at urostomy site Maintain BS for type 2 diabetes 126 to 200, monitor meal Evaluate pain level Qshift. consumption READ BACK: (Verify understanding) Student Nurse: Erin Yuslum ,SN. Evinyislen, SN 1300 Fundamentals Assessments Page 3 of 8 CALEN OF NURSING GALEN FUNDAMENTALS ASSESSMENT DEMOGRAPHICS: Admitting Diagnosis: Sepsis following procedure Allergies: NKDA Height: 5ff in Weight: 171 Sex: M Past History: HTN, GERD, CKD Stage 3, Malignant neoplasm of bladder, Type 2 diabetes, muscle weakness Code Status: (Select) Full Code DNR Other: Advanced Directive Isolation Precautions: (Select) Standard Contact Droplet Other Activity: PT to engage active ROM excercises for Dlet: CCHO muscle wealiness build strength. Vital Signs: 0700 Pain: LUE HR 72 RR 18 SpO2: Temp: 96.9 (Select one) Temporal (Select one) Room Air NC Mask at Oral Axillary Tympanic NEUROLOGICAL ASSESSMENT Oriented to: Person Place Time Situation Level of Consclousness Alert Lethargic Stupor Unresponsive Communication: Verbal Communication Communication Dysarthria Receptive Aphasia Expressive Aphasia Pupils: PERRLA OR: Pupil Size: R: L. Round: Yes No Accommodation: Right Left Reactivity to Light: Right: Brisk Sluggish No Reaction Left: Brisk Sluggish No Reaction Response to Commands: Follows commands Attempts to follow commands No attempt to follow commands Location: Muscle Strength Sensation Tremor (Select one for each (Select one for each location) location) (Select one for each location) Strong Weak Touch Pain only No response to pain No Present Right Hand Strong Weak Touch Pain only No response to pain No Present Left Hand Strong Weak Touch Pain only No response to pain No Present Right UE: Strong Weak Touch Pain only No response to pain No Present Left UE: Strong Weak Touch Pain only No response to pain No Present Right LE: Strong Weak Touch Pain only No response to pain No Present Left LE: Strong Weak Touch Pain only No response to pain No Present Comments: MUSCULOSKELETAL ASSESSMENT Movement: Full range of motion appropriate for developmental age: Yes No Describe: muscle weakness Developmentally independent ambulation: Yes No Describe: Assistive Ambulation Devices: front wheeled in LLE, RLE cuse of assistive devices. Gait: (select one) Steady Unsteady Shuffle Limp R Limp L Comments: Lower extremity bilateral muscle weakness. Fundamentals Assessments Page A of 8 CALEN OF NURSING GALEN FUNDAMENTALS ASSESSMENT DEMOGRAPHICS: Admitting Diagnosis: Sepsis following procedure Allergies: NKDA Height: 5ff in Weight: 171 Sex: M Past History: HTN, GERD, CKD Stage 3, Malignant neoplasm of bladder, Type 2 diabetes, muscle weakness Code Status: (Select) Full Code DNR Other: Advanced Directive Isolation Precautions: (Select) Standard Contact Droplet Other Activity: PT to engage active ROM excercises for Dlet: CCHO muscle wealiness build strength. Vital Signs: 0700 Pain: LUE HR 72 RR 18 SpO2: Temp: 96.9 (Select one) Temporal (Select one) Room Air NC Mask at Oral Axillary Tympanic NEUROLOGICAL ASSESSMENT Oriented to: Person Place Time Situation Level of Consclousness Alert Lethargic Stupor Unresponsive Communication: Verbal Communication Communication Dysarthria Receptive Aphasia Expressive Aphasia Pupils: PERRLA OR: Pupil Size: R: L. Round: Yes No Accommodation: Right Left Reactivity to Light: Right: Brisk Sluggish No Reaction Left: Brisk Sluggish No Reaction Response to Commands: Follows commands Attempts to follow commands No attempt to follow commands Location: Muscle Strength Sensation Tremor (Select one for each (Select one for each location) location) (Select one for each location) Strong Weak Touch Pain only No response to pain No Present Right Hand Strong Weak Touch Pain only No response to pain No Present Left Hand Strong Weak Touch Pain only No response to pain No Present Right UE: Strong Weak Touch Pain only No response to pain No Present Left UE: Strong Weak Touch Pain only No response to pain No Present Right LE: Strong Weak Touch Pain only No response to pain No Present Left LE: Strong Weak Touch Pain only No response to pain No Present Comments: MUSCULOSKELETAL ASSESSMENT Movement: Full range of motion appropriate for developmental age: Yes No Describe: muscle weakness Developmentally independent ambulation: Yes No Describe: Assistive Ambulation Devices: front wheeled in LLE, RLE cuse of assistive devices. Gait: (select one) Steady Unsteady Shuffle Limp R Limp L Comments: Lower extremity bilateral muscle weakness. Fundamentals Assessments Page A of 8 COME OF NURSING RESPIRATORY ASSESSMENT Oxygenation Status: Sp02 (Select one) Room Air NC Mask at RR: 8 Cough: (Select one) None Productive Sputum Description: Respiratory Effort: Labored Describe: Respiratory Pattern Regular Irregular (Select pattern If Irregular) Tachypnea Bradypnea Hyperventilation Hypoventilation Breath Sounds: Areas Auscultated: (Select) RUL Anterior Clear throughout Posterior Both Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RML Clear throughout Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RLL Clear throughout Decreased Fine Crackles Course Crackles Wheeres Friction Rub Rhonchi Absent Breath Sounds: Areas Auscultated: (Select) LUL Anterior Clear throughout Posterior Both Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RLL Clear throughout Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent Comments: GASTROINTESTINAL ASSESSMENT Abdomen: (Select applicable) Mass Lesions Bulges Distension Tenderness None Bowel Movements: Date of last bowel movement: Continence: Continent of stool Incontinent of stool Comments: Brown formed soft no foul odor Method of Output: nodifficility. Tollet Bedside Commode Bedpan Brief Ostomy None Present Describe: Bowel Sounds: (Select one) RUQ Active Hyperactive Hypoactive Absent (after 5 full minutes) LUQ Active Hyperactive Hypoactive Absent (after 5 full minutes) RLQ Active Hyperactive Hypoactive Absent (after 5 full minutes) LLQ Active Hyperactive Hypoactive Absent (after 5 full minutes) Tube Feeding: None NG Tube Method of placement verification: Stoma: None Pink Deep Red Dusky Comments: Retracted Ostomy care: Provided RN Roxanne Fundamentals Assessments Page 6 COME OF NURSING RESPIRATORY ASSESSMENT Oxygenation Status: Sp02 (Select one) Room Air NC Mask at RR: 8 Cough: (Select one) None Productive Sputum Description: Respiratory Effort: Labored Describe: Respiratory Pattern Regular Irregular (Select pattern If Irregular) Tachypnea Bradypnea Hyperventilation Hypoventilation Breath Sounds: Areas Auscultated: (Select) RUL Anterior Clear throughout Posterior Both Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RML Clear throughout Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RLL Clear throughout Decreased Fine Crackles Course Crackles Wheeres Friction Rub Rhonchi Absent Breath Sounds: Areas Auscultated: (Select) LUL Anterior Clear throughout Posterior Both Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent RLL Clear throughout Decreased Fine Crackles Course Crackles Wheezes Friction Rub Rhonchi Absent Comments: GASTROINTESTINAL ASSESSMENT Abdomen: (Select applicable) Mass Lesions Bulges Distension Tenderness None Bowel Movements: Date of last bowel movement: Continence: Continent of stool Incontinent of stool Comments: Brown formed soft no foul odor Method of Output: nodifficility. Tollet Bedside Commode Bedpan Brief Ostomy None Present Describe: Bowel Sounds: (Select one) RUQ Active Hyperactive Hypoactive Absent (after 5 full minutes) LUQ Active Hyperactive Hypoactive Absent (after 5 full minutes) RLQ Active Hyperactive Hypoactive Absent (after 5 full minutes) LLQ Active Hyperactive Hypoactive Absent (after 5 full minutes) Tube Feeding: None NG Tube Method of placement verification: Stoma: None Pink Deep Red Dusky Comments: Retracted Ostomy care: Provided RN Roxanne Fundamentals Assessments Page 6 GATEN COMICS OF NURSING 0 Intake Substance (ex. Juice) Unit of measurement (mL) Intake Route (PO, Enteral, IV) water x2 120mL PO Tea 60mL PO coffee 240mL PO Juice 240mL Totals: 660mL Output Substance Unit of measurement Collection Method (mL or volds. Emesis In mL) urostomy (ox. Toilet, hat, foley) 600mL leg bag collection Totals: 600mL Fluid Balance: Encouraged pt to increase fluid intake. GENITOURINARY ASSESSMENT Urination: urostomy bag collection Urine Characteristics: Continence: Continent of urine Yellow, clear, no parti wates present Incontinent of urine Method of Output: Toilet Bedside Commode Bedpan Brief Ostomy Purwick Catheter Catheter: None Foley Condom Comments: RN Royanne provided ostomy care. Fundamentals Assessments Page 7 of GATEN COMICS OF NURSING 0 Intake Substance (ex. Juice) Unit of measurement (mL) Intake Route (PO, Enteral, IV) water x2 120mL PO Tea 60mL PO coffee 240mL PO Juice 240mL Totals: 660mL Output Substance Unit of measurement Collection Method (mL or volds. Emesis In mL) urostomy (ox. Toilet, hat, foley) 600mL leg bag collection Totals: 600mL Fluid Balance: Encouraged pt to increase fluid intake. GENITOURINARY ASSESSMENT Urination: urostomy bag collection Urine Characteristics: Continence: Continent of urine Yellow, clear, no parti wates present Incontinent of urine Method of Output: Toilet Bedside Commode Bedpan Brief Ostomy Purwick Catheter Catheter: None Foley Condom Comments: RN Royanne provided ostomy care. Fundamentals Assessments Page 7 of MEDICATION ASSESSMENT Drug Dosal Route Frequency Patient Sportile (limitication 28 Artium I illegible_ntt Indication (Select) of g Anticoegulant inducing bronchies remounts Antibiotic mede dieunes Stool Softsner and Ten MD or Discount regularly, 0 m ray about S Opioid snacing innobing immediate needs of rear providers cate a Diuretic hypergenemisty or Other a mediator schese, Admarge Reactions E particularly Chost pain BP rd from most cells irregister hearther 00 rapid breathing confusion Anticoagulant relaxes the Stomach pain Issuric potent 55 Antibiotic Stool Softener blood vessels numera thresness befor taxing of to adidas and a to Opioid und lowers Sleepinks avoid not sauha awards and aming blood pressure, and integistered Z Diaretic increases the fluenths t Other Supply of blood Adverte Sections System Steer 1 and oxygen to Hypotension BP, (s) I confusion the neart while Heart smack reaucing HS wor Kidda. Anticoagulant Decreases the Headache Educate patient on imposses Antibiotic amount of acid abdominal pain of taking ma 06 personal Stool Softener Educate patient to Swelley nine Opioid the stomach Do not breassission you makes and causes Diuretic helps heal acid Adverte Reactions Patient See Concerns Other proton pump damage low magnesium inhibitor stomach and muscle spooms ENS side effects gastric proliferative Change, (PPI) esophagus. signs of lupus feizures Fall precauting Irregular heartbeed Anticoagulant Antibiotic Stool Softener Opioid Diuretic Other: Adverse Reactions MEDICATION ASSESSMENT Drug Dosal Route Frequency Patient Sportile (limitication 28 Artium I illegible_ntt Indication (Select) of g Anticoegulant inducing bronchies remounts Antibiotic mede dieunes Stool Softsner and Ten MD or Discount regularly, 0 m ray about S Opioid snacing innobing immediate needs of rear providers cate a Diuretic hypergenemisty or Other a mediator schese, Admarge Reactions E particularly Chost pain BP rd from most cells irregister hearther 00 rapid breathing confusion Anticoagulant relaxes the Stomach pain Issuric potent 55 Antibiotic Stool Softener blood vessels numera thresness befor taxing of to adidas and a to Opioid und lowers Sleepinks avoid not sauha awards and aming blood pressure, and integistered Z Diaretic increases the fluenths t Other Supply of blood Adverte Sections System Steer 1 and oxygen to Hypotension BP, (s) I confusion the neart while Heart smack reaucing HS wor Kidda. Anticoagulant Decreases the Headache Educate patient on imposses Antibiotic amount of acid abdominal pain of taking ma 06 personal Stool Softener Educate patient to Swelley nine Opioid the stomach Do not breassission you makes and causes Diuretic helps heal acid Adverte Reactions Patient See Concerns Other proton pump damage low magnesium inhibitor stomach and muscle spooms ENS side effects gastric proliferative Change, (PPI) esophagus. signs of lupus feizures Fall precauting Irregular heartbeed Anticoagulant Antibiotic Stool Softener Opioid Diuretic Other: Adverse Reactions CARE PLAN Student Name. Select Type: X Problem Focused Risk Nursing Diagnosis Health Promotion Date: Pt. Age: 82 Medical Diagnosis: Sepsis Assessment Nursing Data Scientific NANDA Interventions What did you look at Rationale to determine a Nursing Patient Goal What is Indicated for Why is the intervention Did the patient work? reach was done a the IN the Goal 60317 not Evaluation Did each the management of indicated? problem? What do you hope will be the result of your as each nationale in APA intervention Data from Diagnosis this particular efforts? format What should x else mez? problem? Example (Ackley, 2017) assessment What interventions will include (ull APA reference x goal: help the client meet bottom or on next page for each intext Otation Subjective: goals? Problem: What the patient says goal: Evaluation of 1. Intervention: (Ex: have pain, NANDA approved Patient will: not experi once Assess site of skin impairement Nursing diagnosis an opened area around and determine cause or type of document was nausea, Impaired Skir wound. My urostomy integrity ostomy site Rationale: Identification o fskin keeps leaking As exhibited : Citation) etiological v What caused the factors, or what is causing the assessment Goal If goal opened Patient met. met: data that not area demonstrates of must goal shift. are the and goal not the ex ostomy person my pain level intact skin problem? the impairement, is the first step an site end medical diagnosis. and requires a thorough assessment the individual not only the If goal partially met must document to the you goal was impal. rement The essment should met. the get assessment : data.) Include medical Hx, current medi this thing urostomy end of shift Intervention Status medications, only assessment Goal partially partially data met that Document demonstrates additional what else should be fixed and familynx(Bardnoskie Ayello Mur phee, 2017) interventions done or changed need to be added?).I in plan (do leakaye Objective: As evidenced goal: Rationaler Measurable (Ex: VS, Labs, Drainage, etc.) : Patient will: demonstrate (APA In Text Citation) Prostate How do you know a management problem exists? removed of urostomy Goal not met. you document If goal not met: assessment that demonstrates the goal was not bilateral data from column 1 met. Document what else should be done or muscle weakness As exhibited : that supports the changed in the plan (do additional interventions urine leaking nursing diagnosis. Intact Skin 2 Intervention: Inspect monitor need to be bag from Urostomy Site of skin impairementat and connections around least once daily for color change, pink, Henderness ostomy. eryjhima, edema, warmtn, pain : Rationale: Changes in sensation moisture, site. around discharge In Text Citation) or other si ansof not do AEB part If 3: infection. the options that do not apply to the evaluation of your ostomy RISK as there must be related to NSG diagnosis la patient oriented Is monitor the clients skin care goal (Example: if your patient met their short term goal delete the will be no evidence since realistic to is measurable is time partially and Act mer options) site specific in 2 weeks, in 1 month, discharge, etc practices noting type of coap, or other the patient have As exhibited what would demonstrate the patient meeting the condition and is only cleansing agents used temp of watter, the goal, All interventions must directly impact the goals that were are and at risk for it at this time. patient specific, Include APA referenced rationale. when do you want them to achieve. frequency of skin cleansing. CARE PLAN Student Name. Select Type: X Problem Focused Risk Nursing Diagnosis Health Promotion Date: Pt. Age: 82 Medical Diagnosis: Sepsis Assessment Nursing Data Scientific NANDA Interventions What did you look at Rationale to determine a Nursing Patient Goal What is Indicated for Why is the intervention Did the patient work? reach was done a the IN the Goal 60317 not Evaluation Did each the management of indicated? problem? What do you hope will be the result of your as each nationale in APA intervention Data from Diagnosis this particular efforts? format What should x else mez? problem? Example (Ackley, 2017) assessment What interventions will include (ull APA reference x goal: help the client meet bottom or on next page for each intext Otation Subjective: goals? Problem: What the patient says goal: Evaluation of 1. Intervention: (Ex: have pain, NANDA approved Patient will: not experi once Assess site of skin impairement Nursing diagnosis an opened area around and determine cause or type of document was nausea, Impaired Skir wound. My urostomy integrity ostomy site Rationale: Identification o fskin keeps leaking As exhibited : Citation) etiological v What caused the factors, or what is causing the assessment Goal If goal opened Patient met. met: data that not area demonstrates of must goal shift. are the and goal not the ex ostomy person my pain level intact skin problem? the impairement, is the first step an site end medical diagnosis. and requires a thorough assessment the individual not only the If goal partially met must document to the you goal was impal. rement The essment should met. the get assessment : data.) Include medical Hx, current medi this thing urostomy end of shift Intervention Status medications, only assessment Goal partially partially data met that Document demonstrates additional what else should be fixed and familynx(Bardnoskie Ayello Mur phee, 2017) interventions done or changed need to be added?).I in plan (do leakaye Objective: As evidenced goal: Rationaler Measurable (Ex: VS, Labs, Drainage, etc.) : Patient will: demonstrate (APA In Text Citation) Prostate How do you know a management problem exists? removed of urostomy Goal not met. you document If goal not met: assessment that demonstrates the goal was not bilateral data from column 1 met. Document what else should be done or muscle weakness As exhibited : that supports the changed in the plan (do additional interventions urine leaking nursing diagnosis. Intact Skin 2 Intervention: Inspect monitor need to be bag from Urostomy Site of skin impairementat and connections around least once daily for color change, pink, Henderness ostomy. eryjhima, edema, warmtn, pain : Rationale: Changes in sensation moisture, site. around discharge In Text Citation) or other si ansof not do AEB part If 3: infection. the options that do not apply to the evaluation of your ostomy RISK as there must be related to NSG diagnosis la patient oriented Is monitor the clients skin care goal (Example: if your patient met their short term goal delete the will be no evidence since realistic to is measurable is time partially and Act mer options) site specific in 2 weeks, in 1 month, discharge, etc practices noting type of coap, or other the patient have As exhibited what would demonstrate the patient meeting the condition and is only cleansing agents used temp of watter, the goal, All interventions must directly impact the goals that were are and at risk for it at this time. patient specific, Include APA referenced rationale. when do you want them to achieve. frequency of skin cleansing.
Clinical Packet 8: Nursing Fundamentals Assessment Reflection
Course: Fundamentals (NUR155)
University: Galen College of Nursing
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